Vascular access indicators added to health authority reports
Starting this month, two new vascular access (VA) indicators are included in BCPRA’s balanced scorecard, which is submitted to PHSA and reviewed by the Renal Agency executive committee (executive sponsors as well as renal medical and administrative leaders from across all health authority programs), as well as the PHSA board.
The indicators will also be incorporated into health authority-specific versions of the "balanced scorecard," which includes three categories of indicators to track within each renal program and facility: clients, patients and community; service coordination and delivery; and learning, growth and innovation. The new indicators – vascular access prevalence and incidence – will be included in the service coordination and delivery category.
Province-wide VA prevalence and incidence rates have been tracked using PROMIS within the renal community for the past 18 months by the interdisciplinary Provincial Vascular Access Services Team (PVAST). The vascular access prevalence rate report identifies, as of a given date, the number and percentages of different types of vascular accesses in use. The vascular access incidence rate report identifies the number and percentages of different types of vascular accesses in use for all first chronic hemodialysis runs during a specific time period.
Target VA prevalence rates (as established by PVAST) are: arteriovenous fistulas (AVFs): >60%; arteriovenous grafts (AVGs): >20%; catheters: <20%. The provincial rate as of September 30, 2008 was 58% for fistulas/grafts, 7% for fistulas/grafts and hemodialysis catheters, and 36% for hemodialysis catheters. The provincial fistula/graft rate remained relatively constant from the previous period (59% in Sept/07 vs 58% in Mar/08), and the provincial catheter rate remained the same between the two periods (42%).
Target VA incidence rates (as established by PVAST) are: AVF/AVG: >50% and catheter: <50%. The provincial incidence rate from April 1/08 – Sept 30/08 was 19% for fistulas/grafts, and 81% for hemodialysis catheters. The provincial fistula/graft incidence rate decreased in the current period over the previous two periods (19% in the current period vs 24% in each of the two previous periods). The provincial catheter incidence rate increased compared to previous periods (81% in the current period vs 76% and 75% in the two previous periods).
As well as being included in the health authority management indicator reports, data at the dialysis centre and patient levels are available as standard PROMIS reports and accessible by anyone with authorized access. The reports will allow the PVAST and Renal Agency medical advisory and executive committees to identify trends as well as develop and monitor improvements.
Check out the BC Renal Agency website for the range of tools and documents developed by the PVAST team: guidelines and reports (including a VA clinic best practices report and a referral processes document), a series of teaching pamphlets for patients, VA clinic forms, and more.
Easing transition to adulthood for young patients
The transition from the teenage years to adulthood is difficult for many young people, but for young people with kidney disease it can be considerably more complicated, and fraught with potential for health problems.
According to pediatric nephrologist, Dr. Mina Matsuda-Abedini, the problem is that many young people reaching adulthood aren’t ready to take on responsibility for their own renal care. The result is an unacceptably high rate of negative outcomes for these patients following their transfer of care to adult services – a phenomenon observed among young renal patients in many parts of the world.
To help address this issue, Mina, with the support of Dr. Doug Matsell and the Renal Agency, was instrumental in setting up the Pediatric Nephrology Transition Clinic at BC Children’s Hospital in January 2007. Nearly two years later, the early evidence is that the multidisciplinary team assessment and education provided by the program is making a difference.
The clinic offers its patients the services of a team of professionals, including a pediatric nephrologist, renal nurse, adolescent/youth health specialists, renal pharmacist, renal dietitian and social worker. The team uses educational and behaviour strategies and other methods to encourage its young patients to adhere to their treatment plans, and no patient is transferred to adult care unless all members of the team are satisfied the patient is as ready as he or she can be.
The clinic also helps the parents of its young patients, as they too must go through a transition process toward supporting the increased responsibility of their young adult children for their own renal care.
Since the start of the clinic, 40 patients aged 17 to 20 have been evaluated, and 23 have been successfully transferred to adult care. In future the clinic could accept patients as young as 14, depending on their emotional maturity.
"This is a patient population that requires special attention to ensure better health outcomes," says Mina. "The concept is to educate and empower our young patients and to give them the tools they need to become an active participant in their own care."
PROMIS update
BC Transplant database to merge with PROMIS
A decision to integrate BC Transplant’s clinical database (TADIS) into the Renal Agency’s PROMIS database was announced at BC Nephrology Days by Provincial Health Services Authority (PHSA) senior vice president Brian Schmidt, executive sponsor of the initiative.
The replacement of TADIS, which was developed almost 20 years ago, was highlighted as a priority in BC Transplant's strategic plan. Merging TADIS with PROMIS offered a logical solution, given the significant overlap in patient populations between the two organizations (fully two-thirds of organ transplants involve kidney patients) and its cost effectiveness.
PHSA has appointed Darlene Holmes as the project manager responsible for supporting teams from BC Transplant and BCPRA to integrate the two systems.
PROMIS adopted by Manitoba Renal Programs
Manitoba’s renal programs have decided to adopt the BC Renal Agency’s PROMIS clinical information system following an extensive review of database systems, which identified PROMIS as "the only system available" that would meet their needs.
Bringing Manitoba’s renal programs into PROMIS offers a number of benefits to the BC renal network, including shared development costs and increased system capacity. Renal programs in Saskatchewan and Ontario have also expressed interest in the PROMIS database, which was recognized in 2005 by Accreditation Canada as a "leading practice." PROMIS is fully aligned with provincial and national e-health strategies and e-health legislation.
Improving clinical care for CKD patients
Cecilia Li and her colleagues at the chronic kidney disease (CKD) clinic at Vancouver General Hospital (VGH) are on a mission. Through basic changes to the way they operate, the team expects to significantly increase their productivity and the quality of care they provide for patients at the clinic.
Cecilia says when she joined the VGH renal program as patient services manager in spring 2007, people from the program told her they needed more resources. But before asking for more, says Cecilia, "I thought we should first look at how our current resources were being used, to make sure we were operating as efficiently as possible."
That started the ball rolling on a series of process improvement efforts, including group teaching sessions and case management by interdisciplinary teams rather than on a one-to-one basis. To improve patient education, all of the clinic’s educational materials were reviewed and revisions made to better address the learning needs of patients.
"Because 25 percent of our patients don’t speak English, language is one of our biggest challenges for education," says Cecilia. "We also have a lot of older patients who have problems with hearing and eyesight."
To address these challenges, Cecilia says clinic staff are looking at a variety of changes to how they provide patient education, from language translations of written and video-based materials, to finding ways of "marketing hope" to patients who come to the clinic feeling depressed about their CKD.
The clinic is currently trying out a new process for clinic visits, involving an interdisciplinary team of renal professionals, including a nephrologist. With key support through PROMIS, the team thinks it could double the number of patients seen in each clinic visit.
Although this initiative is still in trial mode, Cecilia has pegged April 1, 2009 as the "go-live" date for these sessions to become standard for all patients. In the future, she sees an opportunity for even greater efficiency by combining group visits with clinical visits for CKD patients at the VGH clinic.
Many of the operational changes underway at the VGH clinic borrow from the success of similar initiatives at other CKD clinics around the province. Taken together, the changes at VGH represent a significant shift in how its CKD clinic deals with patients. And as various process improvements are implemented, Cecilia and her colleagues are diligently tracking results. Cecilia says patient feedback to date has been largely positive, and by next year she hopes to have evaluation results worthy of publication and sharing with renal network colleagues from across the province at BC Nephrology Days.
Study reveals inconsistent testing for hepatitis B virus
Renal patients on dialysis are regularly tested to make sure their immunization for the hepatitis B virus (HBV) is adequate. If their immunization level is low they are given booster shots.
In a study published in July 2008 by the American Journal of Kidney Disease, a BC team of researchers led by nephrologist Dr. Monica Beaulieu looked at how often BC renal patients on dialysis were re-tested for HBV immunization. The study revealed significant differences in the frequency of HBV testing among renal units across the province and between hemodialysis and peritoneal dialysis (PD) patients.
Comparing actual testing frequencies in BC with the recommended frequency the study found that half of BC’s dialysis patients were tested according to the recommended frequency, while 13 percent of patients were tested less and 37 percent more than the recommended frequency. Patients with current or past HBV infection were tested more than recommended, and hemodialysis patients were more likely than PD patients to be tested more than recommended.
"Although we found guidelines were being used in clinics around the province, there wasn’t one standard set of guidelines followed by everyone," says Monica.
The study concludes that following recommended practices for HBV retesting would ensure appropriate follow-up care and could save the health care system money by reducing the amount of unnecessary retesting.
As an extension of this study, best practices in HBV testing were identified and a standard set of guidelines was developed for clinical use across the province. Further related work includes a follow-up study to see whether the new guidelines are being consistently used, says Monica.
IAMHD Committee – Profile
In-centre nocturnal dialysis program a first in North America
There has been a significant increase in the number of home-based hemodialysis patients since the launch of a provincial program in 2004. Over the past year, the provincial independent hemodialysis committee (IAMHD -- Innovative Approaches to the Management of Hemodialysis) has turned its sights to increasing facility-based independent options.
Last spring, an independent dialysis unit opened in Prince George, and early in 2009, an in-centre nocturnal hemodialysis program will open at Vancouver General Hospital.
The VGH program was developed for patients who want a more independent option, but are unable to participate in home hemodialysis. The four-month pilot program will offer overnight hemodialysis for four patients, three nights a week. The patients have been fully trained to manage their hemodialysis on their own, although a nurse will participate in the nocturnal sessions as an observer.
"To the best of our knowledge, this is the first program of its kind in North America," says IAMHD committee chair, Dr. Michael Copland, provincial medical director of the Renal Agency’s home hemodialysis program. Although nocturnal dialysis has been offered elsewhere, in other jurisdictions the service is simply an extension of regular daytime hemodialysis programs. Patients at the VGH in-centre nocturnal program, however, "will be completely independent," says Michael.
Michael says the program at VGH is expected to eventually offer independent nocturnal hemodialysis to as many as ten patients, in two shifts over six nights a week. The program was developed in direct response to the relatively large number of patients who would choose home hemodialysis but can’t due to unsuitable circumstances in their home environment.
Like other independent dialysis options available to BC patients, the in-centre nocturnal HD program enables patients to take a leading role in the management of their renal care. The program also provides a cost benefit for the renal system by maximizing the use of existing dialysis equipment.
Electronic charting for home hemodialysis patients
Over the past year, all clinical information for patients involved in the independent dialysis programs within Vancouver Coastal Health and Providence Health Care has been available through an electronic charting system. The new system is fully functional and supports medication reconciliation as well as all lab and clinical records for these patients. It also eliminates the need for multiple charts, which are still often required for other renal patients.
Following the success of the new system for Vancouver-area patients, in early 2009 electronic charting will become available for home hemodialysis patients on Vancouver Island. The system will be rolled out to home hemodialysis patients in other health authorities later in the year, and could eventually be expanded to include other renal patients around the province.
Patient Surveys
BC is a leader in the area of independent therapies available for patients with kidney disease, and efforts are ongoing to increase the number of patients choosing peritoneal dialysis and home hemodialysis in this province.
As part of these efforts, from time to time patient surveys are done to identify possible misconceptions or patient concerns about these therapies. The next of these surveys is scheduled for the coming month. In partnership with the health authority renal programs, the BC Renal Agency will survey all CKD patients with a glomerular filtration rate (GFR) of less than 15 ml/min and all in-centre and community-based hemodialysis patients about their interest in independent therapies. At the same time, all PD patients will receive a survey about their interest in home hemodialysis, as an alternative therapy should they be unable to perform peritoneal dialysis.
In addition to identifying patients who might be interested in independent therapies, these surveys help to determine how effectively independent dialysis options are being communicated to patients during their pre-dialysis educational sessions.
In yet another survey, scheduled for December, patients on home hemodialysis across BC will be asked to rate their satisfaction with Gambro - especially as it relates to the technical support that Gambro provides these patients between the hours of 7:00 am and 11:00 pm, seven days a week. The survey will also assess the learning experience of patients on home hemodialysis.
Renal community shows national leadership with med rec
The BC Provincial Renal Agency and the health authority renal programs are breaking new ground in Canada by initiating medication reconciliation for renal patients on dialysis across the province.
Although "med rec" is now a requirement for hospital accreditation and is expected to become standard practice for acute care patients across Canada, it has not been extended to chronic care out-patients anywhere else in the country.
Medication errors have historically been a significant cause of adverse events for patients under care. And renal patients, with their needs for multiple medications and frequent changes to their meds are at a higher risk than most patients for such errors.
"Our goal in expanding our medication reconciliation efforts is to improve patient safety for dialysis patients across the entire continuum of care," says Dan Martinusen, chair of the Renal Agency’s pharmacy & formulary review committee.
With the support of renal program managers and using the PROMIS clinical database, the med rec process has now been initiated for dialysis patients on Vancouver Island, at Fraser Health and in the renal program at St. Paul’s Hospital. The process is expected to be in place for dialysis patients in other areas of the province in the coming year. Eventually the program will also involve the renal agency’s community partner pharmacists.
In addition to improving patient safety, med rec supports such other patient benefits as easier hospital admission and discharge, providing patients with up-to-date medication lists, and better drug-use evaluation at the patient, prescriber and agency level. As a result, clinicians will have tools to better evaluate their practice while providing safer patient care.
"The key to making med rec work for our patients is making sure that every prescription they receive, and every change made to their medication list gets entered in the PROMIS database," says Dan.
The BC Renal Agency website has more information about med rec, including an online tutorial, and a link to a special pharmacy issue of Renal News.
Trust fund dollars support Fraser Health PD care innovation
"Value added funds" from a provincial contract negotiated by the Renal Agency with Baxter Corporation are supporting a Fraser Health pilot project to have a peritoneal dialysis (PD) nurse visit kidney patients in their homes.
The goal of the project is to help patients stay on PD and to reduce the risk of peritonitis by assessing patient practices and making any necessary interventions. Patients may be newly-trained, recovering from peritonitis, recently discharged from hospital, or at risk in some other way, says Fraser Health renal manager Ina Graham.
"We’re looking upstream to anticipate what might cause people to come off PD," Ina explains. "When a nurse goes to the patient’s home she can reinforce aspects of their training, observe their technique and answer any questions they may have."
Feedback from patients has been positive. "These visits really increase people’s confidence levels and reduce their anxiety," says Ina. "PD training is very intense and can be overwhelming – some people need clarification on proper technique after they start to dialyze on their own at home." The project team has observed that in their own homes, patients are more comfortable sharing their concerns.
Post-training, new patients are seen after one week, one month, three months and six months. Patients who have had peritonitis or been in hospital or who are otherwise at risk are seen as often as necessary. The community PD nurse reviews a patient’s medications and blood work and does a physical assessment. The nurse also evaluates the patient’s social support, confidence, home environment, PD practices and troubleshooting ability.
"As well as helping the patients themselves, this project is allowing us to improve our PD training program," says Ina. "The community nurse’s findings are that there are certain things we could emphasize more from the beginning that would make the transition to home easier for patients."
The community PD nursing project wrapped up its initial pilot phase in mid-October, and has been extended for another six months. For more information, contact Ina at ina.graham@fraserhealth.ca
Use of PD trust fund dollars from the provincial contract with Baxter
While a portion of the funds are used at the provincial level to support cross-province PD initiatives of the BC renal network, the majority is allocated to health authority PD programs to meet diverse needs at the local level. Collectively the objective is to optimize the use of PD throughout BC, ensuring quality patient care and enhanced staff knowledge and expertise.
BC renal network attracts international interest
The success of the BC renal network and its model of care continues to attract attention from health care administrators around the world. In August, BC Provincial Renal Agency executive director, Dr. Adeera Levin presented at a special forum for physicians and health care administrators in Western Australia, where she spoke about the structure of the BC renal network, its accountability to the Ministry of Health, and about the role of the PROMIS database in supporting clinical care and quality improvement.
Adeera was invited to speak at the forum following a visit here earlier in the year by health care administrators from Australia’s six states, to learn about the BC renal network. Interest in our system of renal care also extends to the United Kingdom, where Adeera was invited to speak about BC's renal network at a health ministers’ forum in November 2007.
