‘ The Southern Trust Experience ’ Dr John Harty Eamon McBride Southern Health and Social Care Trust
Who Are We?
Late presentation is not a major issue for us
What makes us different?
Access to GFR trends / graphing
Electronic AKI alert system
Efficient Referral / Advice pathway
General Nephrology OPD activity 1200 1000 800 Virtual 600 New 400 200 0 08/0909/1010/1111/1212/1313/1414/1515/1616/17
Timeline • Agreed study in principle in Jan 16. • Software installed but software / IT issues delayed first graphs to August 2016. • JH vetted all graphs subsequently selected by EMcB before sending to GP’s. • This process stopped in May 17 when we had major software issues and lack of local dedicated IT support. • Restarted graphing / medically un-vetted sending in Sept 2017 (including backlog)
Two Stage Process for Graph Selection STAGE 1 • Use the ASSIST-CKD guidelines used in the initial training and also the more recent guidelines from ASSIST-CKD version 4 software. • Use the GAIN guidelines for the ‘Northern Ireland Guidelines for the Management of Chronic Kidney Disease (CKD) as well as tips picked up from Dr Harty
Phase 2: ECR check (OPD, Admissions, Referrals)
Phase 2: ECR Biochemistry • I also check for recent hospital admissions or bloods done in other local laboratories. • It’s especially useful in cases of Acute Kidney Injury (AKI) to check if the GP has repeated the bloods or not, if a repeat has been sent and improvement is observed I refrain from sending a graph. • Don’t send graphs in AKI as alert will have gone to GP
• I approach it however as a review process only, if the decline is sustained (more than one result or steady decrease) and no obvious referral or relevant information I send a graph. • I feel the extra check enforces the graph I am sending out to the GP and minimises the amount of graphs which don’t offer any more clinically to the patient. • I then finalise my list and post the graphs outs keeping a record of all the GPs who receive one for auditing purposes in the future.
Observations • More confident in the process and the software now. • Very important to have the local renal unit involved in the process to monitor outcomes in the coming months and years to see if it adds to the current system in place and if and how it would fit into our current guidelines • Again engage with the local GPs and involve them in the process as well
DHH specific information • Our laboratory systems have identified this patient having a substantial fall in GFR. The red line denotes a graph has been sent to Primary care. • If this patient is not under active follow-up by renal services please consider discussing this patient with the Nephrology service using the Clinical Communications Gateway (CCG). • This biochemistry data does not of course take into account this individual person's overall health or frailty. If after review of this information provided today you feel comfortable to monitor the patient's CKD without contacting the renal team then please do so. • For information about this service please contact Eamon McBride, Biochemistry Department, Craigavon Hospital.Email: eamon.mcbride@southerntrust.hscni.net
Progress to date: Graphs produced 1200 1000 800 600 AGE 0-65, GFR=<50 400 AGE 65-120, GFR =<40 200 0 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Progress to date: Graphs Sent to GPs 25 20 AGE 0-65, GFR=<50 AGE 65-120, GFR =<40 15 10 4% of vetted 5 graphs are sent to GP’s 0 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
Summary: Aug 16 – April 17 45 40 35 30 25 < 65 years 20 15 > 65 years 10 5 0 Letter to No Letter Graph Known Died Recovered GP Sent
Progress Summary • Approximately 1/3 of patients were already known to the Renal Service • A similar number (1/3) had clearly a reason for deterioration and would not benefit at that point from nephrology input – Nephrectomy – Advanced cardio-renal failure • 31% of patients > 65 were clearly in a terminal decline and would not benefit from referral. • Up to 7% may benefit from referral
Final Thoughts • ASSIST-CKD is more than a referral guide – Encourage communication – Educational tool • Ongoing monitoring / tests • Re-Referral Guidelines • Pharmacological advice • Conservative care advice • Like Brexit, we are moving into an uncertain time with our GP colleagues. ASSIST-CKD may become a key aspect of our CKD care
We have a nice view
We have adopted these guidelines along with our local Below are a brief overview of the guidelines from Northern Ireland Guidelines developed by GAIN and the Northern Ireland Nephrology Forum so a graph is sent in the ASSIST: (LABORATORY USER GUIDE & following cases: IT INFORMATION PACK (v4)) • • Patients with a very steep eGFR graph suggest Patients with new CKD 5 (eGFR <15 rapidly changing renal function. This may be mL/min/1.73m2) consistent with either acute kidney injury (AKI) • Patients with new CKD 4 (eGFR 15-29 or acute or chronic kidney disease. These mL/min/1.73m2) patents should be marked and a report sent to • Patients with: requesting clinician. ❖ a sustained decrease in eGFR of 25% or • Patients whose cumulative eGFR results are more and a change in eGFR category deteriorating steadily at a significant rate within 12 months (>10ml/min/year as a guide) and especially ❖ a sustained decrease in GFR of those with the latest eGFR below 30 ml/min. 15mL/min/1.73m2 per year. • In very elderly patients a slow steady decline in • When applying both sets of guidelines the eGFR is less significant than for younger patients following are also considered : (as per GAIN) as the former are more likely to die of other • A sustained fall in eGFR (reduction of >15 causes before their deteriorating kidney mL/min/1.73m2) should be confirmed by function becomes clinically significant. repeating serum creatinine/eGFR within one • Patients with relatively stable eGFR results in month. previous years but where the decline has • Progressive CKD is usually defined by at least accelerated (>10/ml/min/year as a guide) within three eGFRs over at least 90 days. the last few months. • • Patients with CKD are referred if they have a A patient with a previous history of declining SUSTAINED decrease in eGFR of eGFR which initially improved and then a second 15mL/min/1.73m2 per year decline has started. Consider these as high risk and review in the second stage. • A graph is sent to help identify these possible scenarios to the GP. Highlighted differences. ✓ The southern trust already has an alert for AKI so a graph is not sent out in these cases. (unless decline sustained) ✓ If they are currently on the renal radar or have been referred as per NIECR review a graph is not sent.
Recommend
More recommend
