Services for Patients with End Stage Renal Failure at ... Shrewsbury and Telford Hospital NHS ... The systems for annual review of patients on the ... Telford patients do not have

West Midlands Renal Network

Services for Patients with End

Stage Renal Failure

at

Shrewsbury and Telford Hospital

NHS Trust

Quality Review Visit Report

Visit date: 29th

September 2009

Report finalised December 2009

SaTH Final Renal Visit Report 2009 12.22.doc 2

CONTENTS

Contents .................................................................................................................................................................... 2

Introduction ............................................................................................................................................................... 3

Acknowledgements ................................................................................................................................................... 3

Renal Services At Shrewsbury & Telford Hospital NHS Trust .................................................................................... 3

Review Visit Findings ................................................................................................................................................. 6

Appendix 1 Membership of Visiting Team .......................................................................................................... 9

Appendix 2 Compliance with Quality Requirements ........................................................................................ 10

Appendix 3 Trust Immediate Risk Action Plan .................................................................................................. 23


INTRODUCTION

This report presents the findings of the peer review visit to services for patients with end stage renal failure (ESRF) at

Shrewsbury and Telford Hospital NHS Trust which took place on 29th September 2009. The purpose of the visit was to

review compliance with the West Midlands Renal Network’s Quality Requirements for the Care of Patients with End

Stage Renal Failure, including Renal Transplantation (2008). The visit was organised on behalf of the West Midlands

Renal Network by the West Midlands Quality Review Service. This report describes one aspect of quality: the extent

to which the service complies with national guidance on the organisation of services for patients with end stage renal

failure. Other indicators for the quality of the service provided are available from the Renal Registry:

http://www.renalreg.com

ACKNOWLEDGEMENTS

The West Midlands Renal Network and West Midlands Quality Review Service would like to thank the staff and

patients of Shrewsbury and Telford Hospital NHS Trust for their hard work in preparing for the review and for their

kindness and helpfulness during the course of the visit. Thanks are also due to the visiting team (Appendix 1) and

their employing organisations for the time and expertise they contributed to this review.

RENAL SERVICES AT SHREWSBURY & TELFORD HOSPITAL NHS TRUST

Service

(as at October 2009) Patient Numbers Number of Stations

Haemodialysis

- Main Unit

- Satellite Unit:

o Princess Royal, Telford

- Home

110

80

2

24

20

-

Total haemodialysis 192

Peritoneal dialysis 74

Transplant follow up 125

TOTAL 391

Permanent dialysis access 68%

Shrewsbury and Telford Hospital NHS Trust (SaTH) serves a population of 500,000 people living in Shropshire and Mid-

Wales. The Renal Service is based at the Royal Shrewsbury Hospital (RSH). There is also a satellite unit at the Princess


Royal Hospital (PRH), Telford. The Renal Department cares for over 350 patients who are receiving dialysis or have a

functioning renal transplant.

CHRONIC HAEMODIALYSIS

There are 24 haemodialysis (HD) stations at Royal Shrewsbury Hospital (RSH), running twilight shifts, three days per

week, giving a capacity of 120. In addition, the unit at RSH also dialyses the acutely ill chronic haemodialysis patient

and provides the region’s acute renal failure (ARF) dialysis service. Excluding ARF patients, 110 patients are currently

dialysing at RSH. The Princess Royal Hospital satellite unit is large having 20 stations. It doesn’t currently run a

twilight shift, and is kept maximally occupied with 80 patients.

PERITONEAL DIALYSIS (PD)

Continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) are utilised by the

peritoneal dialysis department. The Trust is currently exploring the development of a community ambulatory

peritoneal dialysis (APD) program. The Trust has 37 patients receiving peritoneal dialysis, 11 with manual exchanges

and 26 receiving APD.

HOME HAEMODIALYSIS

The Renal Department has a fledgling home haemodialysis (HHD) program. Currently 2 patients have home

haemodialysis (HHD) but with renewed effort to provide this modality to patients and, with the appointment of a lead

HHD nurse, numbers are expected to increase soon.

PLASMAPHERESIS/PLASMA EXCHANGE

The Royal Shrewsbury Hospital haemodialysis unit also provides a plasmapheresis/plasma exchange service, which is

used for renal, haematology and neurology cases. Numbers requiring this treatment are, however, small and average

six per year.

RENAL TRANSPLANT RECIPIENTS

University Hospital Birmingham (UHB) provides the transplant service for the majority of the Trust’s patients, though

those requiring desensitization are provided for by University Hospitals Coventry and Warwickshire (UHCW). ABOi

transplants are also done at UHB. The Trust has recently had its first two combined kidney pancreas transplants

performed at Manchester. The majority of patients have their transplant care transferred back to the Trust three

months after transplantation. The Trust is currently caring for 125 transplant recipients. Through developing links

and supporting UHB, the Trust has been very successful in increasing the number of patients receiving Live Donor

Transplants. They are currently exploring ways, with the support of UHB, to increase the profile of live donation


locally and support the initial stages of donor assessment. There are currently 68 patients on the renal transplant

waiting list.

IN- PATIENT FACILITIES

Currently there are 18 beds on a renal ward, shared between three consultants. A further 12 beds on the same ward

are designated for patients with hematological disorders


REVIEW VISIT FINDINGS

ACHIEVEMENTS

This service has been through a time of significant change. The adequacy of dialysis and control of infection have

improved. Many other aspects of the service have changed. It is clear that these improvements have been made

through the contributions of all members of the renal team. The commitment, working relationships within the team,

and leadership are very good and all should be commended on the progress they have achieved. Patients were very

appreciative of the service they receive. The improvements made to the waiting room, storage areas and procedure

room are very good. The dietitian has audited implementation of the policy of dietary reviews to ensure that all

patients are being reviewed at the expected frequency.

IMMEDIATE RISKS

1 Dialysis concentrates are frequently “trimmed” with potassium supplements to compensate for low post

dialysis potassium levels. The visiting team considered that this had the potential for error and was not

necessary as a sufficiently wide range of concentrates is now available.

2 There are three consultant nephrologists and no nephrology-specific on call rota. A consultant nephrologist

is therefore not usually available at nights and weekends. The Trust has approved a fourth consultant post

and this post will be advertised shortly.

3 The acute dialysis area has no piped oxygen or suction. The space is small for the number of patients being

dialysed and is a long way from the renal ward. Patients for out-patient dialysis walk through the acute area

to reach the out-patient area. The visiting team was seriously concerned about the management of

emergencies, including cardiac arrests, in this environment.

CONCERNS

1 Arrangements for the management of patients pre- and post-transplants are not yet robust. There is not a

co-ordinated process for getting clinically appropriate patients onto the transplant list six months before the

predicted start of dialysis. The systems for annual review of patients on the transplant list and follow-up

post-transplant are not formalised. These reviews take place in general clinics where there is unlikely to be

time adequately to cover all the expected areas. There are three named link nurses for transplant-related

issues which does not give focussed support for the development and implementation of transplant-related

policies and procedures.


2 There is not a 24 hour emergency vascular surgery service. Vascular surgery is provided on two sites (RSH

and PRH). At the time of the visit, plans to bring these services together were out to consultation. There are,

however, insufficient vascular surgeons to run a 24 hour rota. There are informal arrangements for covering

emergencies but these do not ensure a consistent service for patients needing emergency surgery.

3 The Trust is not yet meeting the National Service Framework target of 80% of haemodialysis patients having

permanent dialysis access and, at the time of the visit, 32% patients had temporary lines. Patients are

waiting a long time (two months) to be seen at vascular access clinics, although waits between clinic and

surgery are fairly short. There is only half an elective theatre list every two weeks for renal vascular access.

4 Patients at the Telford satellite unit do not have access to the same services as patients at Shrewsbury.

Telford patients do not have free parking and often have difficulty finding a parking space. There is no

dedicated social work support. Arrangements for making sure patients have had sufficient food are different

from Shrewsbury and the arrangements for allocation of a named nurse/key worker are not clear. The

visiting team was concerned about this issue because of the size of the unit and the dependency of the

patients being dialysed there.

FURTHER CONSIDERATION

1 Many of the policies, procedures and clinical guidelines have been developed recently. The visiting team

commended the progress that has been made. It is important that this work continues to ensure that they

are finalised, ratified and fully implemented. Staff currently have different expectations of the ratification

process and this will need to be clarified.

2 Very good patient information is available (see good practice) but the arrangements for ensuring that all

patients are offered this information are not clear.

3 Allied health professional staffing is below the recommended levels (see QR24). Dietitian and social work

staffing levels are below the recommended level. There is no pharmacist or psychologist time specifically

allocated to the renal service.

4 There is not yet a clear plan for the future development of nursing staff. Link nurses are identified for

specialist areas but some nurses have several roles (for example, pre-dialysis care, vascular access and

anaemia management) and the link nurses are also rostered to the dialysis unit. The establishment appears

to be large and senior enough to create lead roles for each area with a reduced clinical workload.

5 Patients have pre-operative abdominal shaving prior to peritoneal catheter insertion. The visiting team

commented that this is no longer current practice in most other units.


6 The allocation of in-patient beds to renal services is about to change. It will be important to keep this under

review to ensure that sufficient in-patient beds are available for renal patients.

GOOD PRACTICE

1 There is very good patient information, including a Chronic Kidney Disease Information Manual and a folder

on Social Support for Renal Patients.

2 There are very good arrangements for offering a cooked meal to patients each day, especially those who are

elderly and those in care homes who may otherwise miss out on a cooked meal that day.

3 Seven days a week support is available for patients on peritoneal dialysis.

4 The renal service has developed good local action plans for each network-wide audit.

5 The service has implemented a very good MES Quality Management System. This is used well at present and

there are plans to develop its use in the future.

COMPLIANCE WITH QUALITY REQUIREMENTS

Compliance with individual quality requirements is shown in Appendix 2. Overall, the Trust met 63% of the quality

requirements for patients with end stage renal failure.


APPENDIX 1 MEMBERSHIP OF VISITING TEAM

Dr Steve Smith Consultant Nephrologist Heart of England NHS Foundation Trust

Dr Simon Fletcher Consultant Nephrologist University Hospitals Coventry and

Warwickshire NHS Trust

Helen Perkins Lead Nurse Dudley Group of Hospitals NHS Trust

Paula Mitchell Senior Nurse University Hospital Birmingham NHS

Foundation Trust

Carl Richardson Ward Manager Heart of England NHS Foundation Trust

Roger Moore Chief Renal Technician Royal Wolverhampton Hospitals NHS Trust

Paul Gibara Business Manager University Hospitals Coventry and


Beverley Beynon-Cobb Dietitian University Hospitals Coventry and


Dawn Roach User Reviewer

Nick Flint User Reviewer

Dr Jonathan Howell Specialised Commissioner Specialised Commissioning Team (West

Midlands)

Sarah Broomhead Quality Manager West Midlands Quality Review Service

Jane Eminson Acting Director West Midlands Quality Review Service

APPENDIX 2 COMPLIANCE WITH QUALITY REQUIREMENTS

Ref. Quality Requirement (QR) Met? Comments

1

All

Information should be offered to all patients covering at

least:

Renal disease, including its causation, and physical,

psychological, social and financial impact

Treatment options available

Pharmaceutical treatments and their side effects

Promoting good health, including diet, fluid intake,

exercise, smoking cessation and avoiding infections

Access to benefits advice

Symptoms and action to take if become unwell

Support groups available

Expert Patients Programme (if available)

Renal unit staff and facilities available, including

facilities for relatives

Who to contact with queries or for advice

How to influence local services (QR 87)

Where to go for further information, including useful

websites

Y There is a lot of very good patient

information. Some areas could be clearer,

including:

the psychological impact of renal disease

side effects of pharmaceutical

treatments

facilities for relatives.

2

ARS

CRS

Information should be offered to all patients receiving

pre-dialysis care covering at least:

What are the reasons for starting dialysis

Conservative management

Types of dialysis available and locations of these

services

Self-care options

Potential complications of each type of dialysis

Access types and access surgery

Transport options and eligibility for free transport

Availability of, and eligibility for, temporary dialysis

away from home

Arrangements for six monthly holistic review with

named nurse

Who to contact with queries or for advice


websites

Y Good information is available. Some areas

could be clearer, including:

Eligibility for free transport

Arrangements for six monthly holistic

review with the named nurse

Who to contact with queries and for

advice – specifically for patients at

Telford.

3

ARS

CRS

Information should be offered to all patients with dialysis

access covering at least:

Care of their dialysis access

Management of pain and complications

What to do if problems occur

Y



4

All

Information should be offered to all patients being

considered for transplantation covering at least:

Different types of transplantation available and

locations of these services.

Potential complications of each type of

transplantation, including the risks of infection and

malignant disease.

Likely outcomes of each type of transplantation

Tests and investigations that will be carried out.

What will happen if they are accepted for inclusion on

the transplant list

Annual review while on the transplant list.

What will happen if they are not accepted onto the

transplant list.

Who to contact with queries or for advice.


websites.

Y

5

All

Information on kidney donation should be offered to all

patients considering live donation and to all potential live

donors covering at least:

What is live donation

Antibody incompatible transplantation

Potential complications for the donor

Payment of expenses, including the time within which

payment should be received and a contact point for

queries over payments

Y

8

ARS

CRS

An education and awareness programme should be

offered to all patients with ESRF. In addition to a general

programme appropriate to all patients and covering all

points in QR 1, specific programmes for particular groups

of patients should cover all points in the relevant QR as

follows:

Patients being considered for dialysis (QR 2)

Patients with dialysis access (QR 3)

Patients on the transplant list (QR 4)

Education and training in the competences needed for

self-care (for patients opting for self-care).

Y

9

All

All patients should be offered:

A written individual care plan

A permanent record of consultations at which changes

to their care plan are discussed

A key worker / named contact.

N Individual care plans are being developed.

Patients are not yet offered a permanent

record of consultations at which changes to

their care plan are discussed. The

arrangements for allocation of a key

worker/named contact are being developed.

10

All

Food should be offered to all patients who are away from

home for more than 6 hours to attend clinic or receive

dialysis.

Y There are very good arrangements for

offering a cooked meal to patients,

especially those who are elderly and those

in care homes who may otherwise miss out

on a cooked meal that day.

11

All

Free car parking should be available close to the dialysis

unit for haemodialysis patients attending for dialysis.

Y Parking is not free for patients attending for

dialysis at the Telford satellite unit. Parking

can be very difficult for these patients.



12

ARS

CRS

The service should have a nominated lead consultant

nephrologist and nominated lead nurse with

responsibility for ensuring implementation of the

Standards for the Care of Patients with End Stage Renal

Failure.

Y

13

All

The service should have a nominated lead consultant and

lead nurse/co-ordinator for:

Pre-dialysis care

Dialysis care

Transplant-related issues, including live kidney

donation and Renal Unit / Transplant Centre liaison.

N Link nurses have these responsibilities.

Some nurses have several roles (for

example, pre-dialysis care, vascular access

and anaemia management). These nurses

are also rostered to the dialysis unit. There

are three named link nurses for transplant-

related issues with no overall lead.

The establishment appears to be large and

senior enough to create lead roles for each

area with a reduced clinical workload (see

also concerns).

14

All

A consultant nephrologist should be available at all times. N There are three consultant nephrologists

and no nephrology-specific on call rota. A

consultant nephrologist is therefore not

usually available at nights and weekends.

The Trust has approved a fourth consultant

post and this post will be advertised shortly.

18

All

The in-patient ward renal nurse and HCA staffing

establishment and ‘on duty’ staffing levels should meet

the recommendations of the National Renal Workforce

Planning Group, taking account of patient dependency, at

all times. (These recommendations are summarised in

Appendix 3).

All nurses and HCAs should be assessed as competent in

the care of patients with renal disease, procedures they

are expected to undertake and equipment they are

expected to use.

Y

19

ARS

CRS

Dialysis service renal nurse and HCA staffing

establishment and ‘on duty’ staffing levels should meet

the recommendations of the National Renal Workforce

Planning Group, taking account of patient dependency, at

all times. (These recommendations are summarised in

Appendix 3).

All nurses and HCAs should be assessed as competent in

the care of patients with renal disease, procedures they

are expected to undertake and equipment they are

expected to use.

Y

20

ARS

The service should have an identified lead nurse with

specialist expertise in each of the following areas:

Vascular access

Anaemia management

Conservative management

Y See comment to QR13.



21

ARS

CRS

Clinical technologist staff should be available to maintain

all equipment, including water treatment equipment.

Clinical technologist staffing for haemodialysis services

should meet the recommended level of 1 wte per 50

haemodialysis patients.

All clinical technologists should have regular assessment

of competence in the maintenance of equipment

appropriate to their role.

Y All technicians (3.5 wte) are included on the

Voluntary Register

22

ARS

CRS

A 24 hour clinical technologist on call service should be

available.

Y There is a 24 hour clinical technologist on

call service. A renal technologist is available

for telephone advice and on site support if

required.

23

ARS

CRS

The service should have:

A nominated coordinator for holiday haemodialysis

Sufficient staff to ensure data collection as required

for QR 97 to 102.

Y

24

All

The following services should be available to provide

support to patients with renal diseases:

Dietetics

Pharmacy

Psychological support

Social worker

Staff providing these services should have specific time

allocated to their work on the Renal Unit and specific

training or experience in caring for people with renal

diseases. Staffing should meet the recommended levels:

One wte dietitian for each:

o 135haemodialysis patients plus additional support

for in-patient care,

o 270 peritoneal dialysis patients,

o 180 low clearance patients and

o 540 transplant patients

One wte pharmacist per 250 RRT patients plus one

wte per 60 transplants per annum

One wte psychological support per 1000 RRT patients

One wte social worker per 140 RRT patients

N 1.7 wte dietitians cover the service and also

cover urology.

There is no pharmacist with specific time

allocated for their work on the renal unit.

There is no psychologist with specific time

allocated for their work on the renal unit

although patients can access the Hamar

Centre for psychological support.

A social worker is available two days per

week (10 hours; 0.3wte) at Shrewsbury.

Patients at Telford do not have access to

renal-specific social work support. Links with

social services in Telford are through referral

to community teams.

The social worker at Shrewsbury does not

have access to an appropriate area to hold

confidential discussions with patients.

25

All

The following support services should be available:

Interpreters

Occupational therapy

Benefits advice

Smoking cessation

Contraception and sexual health

Y



26

ARS

CRS

Emergency and elective surgical services should be

available to provide:

Elective access surgery

Emergency surgery for failed vascular access and

removal of infected peritoneal dialysis catheters

N Patients are waiting a long time (two

months) to be seen at vascular access

clinics. Waits between clinic and surgery are

fairly short. There is only half an elective

theatre list every two weeks for renal

vascular access.

There is not a 24 hour emergency vascular

surgery service. Vascular surgery is provided

on two sites (RSH and PRH). At the time of

the visit, plans to bring these services

together were out to consultation. There

are, however, insufficient vascular surgeons

to run a 24 hour rota. There are informal

arrangements for covering emergencies but

these do not ensure a consistent service for

patients needing emergency surgery.

27

All

Access to dermatology services with expertise in the

management of patients on long-term immuno-

suppressive therapy should be available.

Y

28

All

There should be a nominated transplant co-ordinator

with lead responsibility for live kidney donors.

Y There is a link nurse for each site

37

ARS

CRS

Appropriate facilities for the provision of haemodialysis

should be available. All new facilities should meet the

requirements of HBN 53 (Volumes 1 or 2 as applicable)

and other services should be working towards these

standards. In-patient services should ensure reasonable

separation of patients receiving in-patient and out-

patient care.

N The acute dialysis area has no piped oxygen

or suction. The space is small for the

number of patients being dialysed and is a

long way from the renal ward. Patients for

out-patient dialysis walk through the acute

area to reach the out-patient area. The

visiting team was seriously concerned about

the management of emergencies, including

cardiac arrests, in this environment.

The waiting room, storage and procedure

areas are good.

38

ARS

CRS

All equipment used in the delivery and monitoring of

therapy should comply with the relevant standards for

medical electrical equipment.

Y

39

ARS

CRS

Each unit should have a programme of equipment

replacement.

Y

40

ARS

CRS

A protocol on concentrates should be in use which

ensures that all concentrates used meet the

requirements of BS EN 13867: 2002.

N All concentrates are brought in but extra

potassium is added.

41

ARS

CRS

A routine testing procedure for product and feed water

should be in use which ensures water used in preparation

of dialysis fluid meets the requirements of Renal

Association Guidelines for Haemodialysis (4th

Edition,

2006

Y Water of patients on home haemodialysis is

not currently tested for bacteria and

endotoxins. The Trust is in the process of

replacing the home haemodialysis reverse

osmosis units and developing a testing

regime for home patients.



42

ARS

CRS

A protocol on haemodialysis membranes should be in use

covering:

Use of low flux synthetic and modified cellulose

membranes

Membranes for patients at risk of developing

symptoms of dialysis-related amyloidosis

Membranes for patients with increased bleeding risk

Membranes in patients on ACE inhibitor drugs

Y

43

ARS

CRS

All equipment used in the delivery and monitoring of

therapy should comply with the relevant standards for

medical electrical equipment.

Y

44

ARS

CRS

All fluids used for peritoneal dialysis should comply with

European quality standards.

Y

45

All

Appropriate facilities for isolation of patients should be

available.

Y There are two side rooms on the ward and

two in the dialysis unit. This is sufficient at

present but may not be adequate if the

number of patients on dialysis continues to

grow.

46

All

All weighing scales should comply with Non-Automatic

Weighing Instrument (NAWI) Regulations 2000, part III,

section 38.

Y All scales supplied by the Trust, including

those for home haemodialysis patients meet

the requirements. Scales are not supplied

to patients on peritoneal dialysis.

47

All

The unit’s operational protocols should include:

Allocation of a key worker/named contact at each

stage of the patient’s care

Arrangements for handover of key worker/named

contact between stages of the patient’s care

Ensuring all patients are offered information (QR 1)

and education programmes (QR 8)

Ensuring all patients have a written care plan that is

discussed with the patient:

o following significant changes in circumstances

o at least once a year (see QR 47and 60)

Offering patients a copy of their care plan

Offering patients a permanent record of consultations

at which changes to their care plan are discussed.

Communicating changes to the care plan to the

patient’s GP, including information about changes in

drug treatments and what to do in emergencies.

Arrangements for ensuring patients have up to date

information on their blood results.

N There is a draft protocol which has not yet

been implemented. This does not include

ensuring that patients have a permanent

record of consultations at which changes to

their care plan are discussed.

GP communication after the nurse-led pre-

dialysis clinic goes via the consultants. It

may be helpful to consider direct

communication to the GP from the nurse.



48

All

A protocol covering responsibilities, advice to be given

and actions to be taken, including referral to other

services, should be in use for:

Lifestyle advice and information, including:

o Support for smoking cessation

o Dietary advice, including salt reduction and

alcohol

o Programmes of physical activity and weight

management

o Sexual health, contraception and pregnancy

o Travel and holidays

Monitoring of growth and development (children and

young people only)

Y

49

All

Clinical guidelines should be in use covering:

Monitoring and management of CHD risk factors,

including:

o Anti-platelet therapy

o Lipid reduction therapy

o Control of hypertension

o Calcium and phosphate control

Management of diabetes mellitus

Management of anaemia

N All guidelines were present except for the

management of diabetes mellitus.

50

All

Clinical guidelines should be in use covering indications

and arrangements for referral for psychological support.

N The guidelines cover the arrangements for

referral but not the indications for referral.

51

All

Guidelines, agreed with the specialist palliative care

services serving the local population, should be in use

covering, at least:

Arrangements for accessing advice and support from

the specialist palliative care team.

Arrangements for shared care between the renal

service and palliative care services.

Indications for referral of patients to the specialist

palliative care team for advice.

Y

52

All

The renal service should be aware of local guidelines for

the end of life care of patients.

Y



53

ARS

CRS

A protocol should be in use cover pre-dialysis care. This

protocol should ensure:

Patients are offered information (QR 2), education

programmes (QR 8) and psychological support to

enable them to make an informed choice of dialysis

modality

Assessment of suitability for dialysis

Assessment of home environment for those patients

considering home dialysis (HD & CAPD)

Assessment of the economic impact of dialysis and

possible sources of financial support

Discussion of transport arrangements with each

patient

Recording of the agreed transport arrangements in the

patient’s care plan

The patient’s preferred choice of dialysis modality is

recorded in the patient’s notes/electronic patient

record and care plan.

The protocol should cover arrangements for patients:

With 12 months or more preparation

Presenting less than 12 months before starting

treatment

Needing immediate dialysis at presentation

With failing transplants.

N This protocol has not yet been developed.

54

All

A protocol should be in use covering:

Screening for blood borne viruses

Hepatitis vaccination if required

Monitoring of hepatitis B and C antibodies

Screening for staphylococcus aureus and MRSA

carriage and treatment of carriers.

The protocol should cover arrangements for patients

presenting less than 12 months before starting treatment

and those needing immediate dialysis at presentation as

well as arrangements for patients with 12 months or

more preparation.

N Most aspects of this QR are met in practice

but arrangements and responsibilities are

not yet fully documented. Renal-specific

protocol(s) covering all aspects of the QR,

including arrangements for patients needing

immediate dialysis at presentation, still need

to be formalised.

55

ARS

CRS


Referral for assessment and investigation of suitability

for access surgery

Referral for surgery

Indications for antibiotic prophylaxis

Ensuring patients are given information about their

dialysis access (QR 3).

This protocol should ensure that, whenever possible,

access is established and functioning 6 months before

haemodialysis and four weeks before peritoneal dialysis.

N A protocol is in draft form but is not yet

specific about the stage at which patients

should be referred for access surgery.



56

ARS

CRS

A protocol should be in use covering referral to the

Transplant Centre for consideration of suitability for

transplantation. T his protocol should ensure that:

A discussion with the patient and nephrologist takes

place about their interest in and fitness for

transplantation.

The patient is considered against the network criteria

for each type of transplantation (QR 119).

The resulting decision is recorded in the patient’s

notes / electronic patient record and care plan.

Clinically appropriate patients are normally placed on

the transplant list six months prior to the predicted

start of dialysis.

N A protocol is in draft form. At the time of

the visit, arrangements were not sufficiently

robust to ensure that clinically appropriate

patients are placed on the transplant list six

months prior to the predicted start of

dialysis.

58

All

A protocol should be in use covering referral of patients

with diabetes for combined kidney and pancreas

transplantation.

N

59

All

A protocol should be in use covering suspension and

reinstatement of patients on the transplant list. This

protocol should cover at least:

Regular review of patients suspended from the list

Informing the Transplant Centre that a patient has

been suspended.

Reinstatement of patients onto the list as soon as

clinically appropriate.

Informing the Transplant Centre when a patient is to

be reinstated onto the list.

N A protocol is in draft form but does not yet

define a robust process with clear

responsibilities at each stage.

60

All

A protocol should be in use covering annual review of

patients on the transplant list. The annual review should

cover at least:

Current fitness for transplantation

Risk factors for coronary heart disease

Anaesthetic risk

Co-morbidity

Availability of potential living related donors

Consent for virology and storage for tissue typing

Suitability for combined kidney and pancreas

transplantation

Suitability for antibody incompatible transplantation

Interest in non-heart beating donor transplantation

N Reviews of patients on the transplant list

take place in general clinics and there is no

protocol to ensure that all the expected

issues are covered.

Patients who met the visiting team were

unsure about the arrangements for review

and their current status on the transplant

list.

61

All

A protocol should be in use covering removal from the

transplant list. This protocol should ensure that:

A discussion takes place with the patient about the

reason for removal.

A decision to remove the patient from the transplant

list temporarily or permanently is recorded in the

patient’s notes/electronic patient record.

The Transplant Centre is informed of the decision to

remove the patient from the transplant list

temporarily or permanently.

N A protocol is in draft form but needs further

development to ensure that robust

arrangements are in place.



62

All

A protocol should be in use covering cardiovascular work-

up prior to transplantation. This protocol should ensure

that cardiac investigations are normally completed within

six weeks of referral.

Y The West Midlands protocol is in use.

63

ARS


Self-care options offered by the service

Arrangements for assessing and monitoring

competence of patients opting for self-care

Y Two patients are currently on home

haemodialysis and other patients are being

prepared.

64

ARS

CRS

A protocol should be in use which ensures:

Arrangements for multi-disciplinary review of blood

results

Monitoring of hepatitis B and C antibodies

Frequency of out-patient review

Arrangements for six monthly holistic review with

named nurse

Indications for change of dialysis modality

Arrangements for changing dialysis modality

Y

65

ARS

CRS

A protocol should be in use which ensures a six monthly

holistic review with the patient’s named nurse covering at

least:

Review of biochemistry and referral to members of

the multi-professional team if required

Current medication, compliance and referral to the

renal pharmacist if required

Consideration of nutritional status and indications for

referral to the dietitian for assessment (QR 66 / 67)

Psychological well-being and indications for referral

for psychological support (QR 50)

Lifestyle advice (QR 48)

Transport arrangements

Need for temporary dialysis away from home

The outcome of the holistic review should be

documented in the patient’s care plan.

Y There is a protocol but it was not clear that

this is being followed in practice. The

section on lifestyle advice could benefit

from additional detail.

66

ARS

A protocol should be in use which ensures that:

An interview with the dietitian takes place within one

month of starting dialysis

An annual nutritional assessment is undertaken

Indications for referral to the dietitian at other times

Y The dietitian has also audited compliance

with the protocol.

68

ARS

CRS

A protocol should be in use covering withdrawal of

dialysis. This protocol should ensure that:

A discussion takes place with the patient and their

family / carers about the reason for withdrawal.

A decision to withdraw dialysis is recorded in the

patient’s notes / electronic patient record / care plan.

Referral to palliative care services is made if

appropriate (QR 51 and 52).

N A protocol is in draft form but further

consideration is needed before

implementation.

69

ARS

CRS


Frequency of haemodialysis

Duration of haemodialysis

Measurement of adequacy of haemodialysis

Pre- and post-dialysis blood sampling

Y A good protocol is available.



70

All


Care of temporary and cuffed dialysis lines and arterio-

venous fistulae, including locking solutions and

dressings

Preparing vascular access for haemodialysis

Decontamination of equipment after each treatment

session

Decontamination of equipment after use by patients

with blood bornee viruses.

Y

71

ARS

CRS

A protocol should be in use covering access care and

performance. This should cover at least:

Arrangements for monitoring access performance

Management of access infections

Investigation of AV fistulae or grafts for evidence of

stenosis

Indications for secondary AV access after each episode

of access failure

Management of anxiety and pain

Y There is a good protocol for radiological

review.

72

ARS

CRS

Clinical guidelines should be in use covering:

Modality of dialysis used (CAPD, APD)

Disconnect systems

Type of fluid used including:

o Solutions for patients experiencing infusion pain

o Solutions for patients likely to remain on

peritoneal dialysis for more than four years.

o Indications for use of specialist fluids

Dialysis dose

Y

73

ARS

CRS

Clinical guidelines should be in use covering access care

and performance. This should cover at least:

Peri-operative catheter care

Care of peritoneal dialysis catheters

Management of exit site and tunnel infections

Management of catheter complications (leaks,

obstruction)

Management of anxiety and pain

Y

74

All

Clinical guidelines should be in use covering management

of:

peritonitis

hernias

Y Patients have pre-operative abdominal

shaving for peritoneal catheter insertion.

The visiting team commented that this is no

longer current practice in most other units.

75

All

Clinical guidelines should be in use for patients who have

had renal transplantation covering:

Treatment of acute rejection episodes

Management of chronic allograft damage, including

chronic rejection.

N Guidelines on the treatment of acute

rejection episodes are available. There were

no guidelines for the management of

chronic allograft damage.



76

All

A protocol should be in use covering follow up of patients

following transplantation. This protocol should include:

Monitoring transplant function using eGFR

Monitoring blood pressure

Monitoring other CHD risk factors

Skin surveillance

Consideration of need for referral to pre-dialysis / pre-

ESRF programmes

Contraception and sexual health

Care of mother and baby during pregnancy

Monitoring of growth (children and young people

only)

N Patients are reviewed in general clinics and

it is not clear that these offer sufficient time

and focus on post-transplant issues.

87

All

The unit should have in place:

Mechanisms for receiving feedback from patients and

carers about the treatment and care they receive.

Mechanisms for involving patients and carers in

decisions about the organisation of the services.

Y

88

ARS

CRS

Arrangements should be in place to ensure effective

communication and regular multi-disciplinary discussion

to review the care of pre-dialysis patients. These

arrangements should cover the involvement of, at least,

consultant nephrologists, lead nurse for pre-dialysis care,

dietitian, renal pharmacist, clinical technologist, renal

social worker and vascular access surgeon.

Y

89

ARS

CRS

Guidelines should be in use covering:

Eligibility for free transport

Eligibility for temporary dialysis away from home.

N Guidelines are not clear on eligibility for free

transport.

90

All

Guidelines should be in use covering arrangements for

liaison with consultant diabetologists and consultants in

rehabilitation medicine.

Y Joint clinics are held.

91

All

The unit should have arrangements for taking advantage

of local opportunities for publicising ‘transplant

successes’.

N Arrangements are not clear. Three names

are given for the lead roles on transplant

issues and it is not clear who is actively

engaging with local media on transplant-

related issues.

92

All

The unit should have compared the staffing levels

expected in QRs 12 to 36 and produced a workforce

development plan for addressing significant staffing

shortfalls.

N Staffing shortfalls have been identified but

there is not a clear, agreed plan for

addressing shortfalls in consultant, lead

nurse and AHP staffing.

93

ARS

CRS

Staff from the unit should meet with a representative of

the team at the main Transplant Centre/s to which

patients are referred at least three times a year in order

to review transplant-related patients and issues.

Y

97

All

The unit should be submitting data to the Renal Registry,

regional data set and UK Transplant.

Y

98

All

The unit should participate in agreed network-wide

audits.

Y There are good local action plans following

network-wide audits.



99

ARS

CRS

The unit should have undertaken an annual audit of:

Travel times for dialysis patients, including waiting

times for return journeys

Relationship between timing of access surgery and

start of dialysis

N There was no audit of the relationship

between the timing of access surgery and

the start of dialysis.

100

All

The unit should have undertaken an annual audit of

compliance with its protocols for acceptance, suspension,

annual review and removal of patients on the transplant

list. This audit should include at least:

Relationship between timing of dialysis and listing for

transplantation

Proportion of patients who have had an annual review

Time from work-up to transplantation for living

related donors.

N These audits have not yet been undertaken.


APPENDIX 3 TRUST IMMEDIATE RISK ACTION PLAN

Immediate Risks – Notified to Trust

1 Dialysis concentrates are frequently “trimmed” with potassium supplements to compensate for low post dialysis

potassium levels. The visiting team considered that this had the potential for error and was not necessary as a

sufficiently wide range of concentrates is now available.

2 There are three consultant nephrologists and no nephrology-specific on call rota. A consultant nephrologist is

therefore not usually available at nights and weekends. The Trust has approved a fourth consultant post and this

post will be advertised shortly.

3 The acute dialysis area has no piped oxygen or suction. The space is small for the number of patients being

dialysed and is a long way from the renal ward. Patients for out-patient dialysis walk through the acute area to

reach the out-patient area. The visiting team was seriously concerned about the management of emergencies,

including cardiac arrests, in this environment.

Identified Risk Actions Progress to Date Review Date

Potential errors

associated with the

addition of

potassium trimmers

to acetate dialysis

fluids

Liaise with current suppliers to establish

availability of pre trimmed fluids. Where pre

trimmed alternatives are available agree

concentrates to be used with clinicians and

switch accordingly. Ensure all changes and

rationale for doing so are communicated to

staff on both sites. Ensure dialysis

prescriptions are amended to reflect use of

new fluids.

Pre trimmed acetate fluids

sourced through MTN to

replace the 3 most commonly

trimmed fluids. Clinicians have

confirmed suitability of

available fluid. Stock should be

available for use by 31.10.09.

Awaiting response from Baxter

re pre trimmed AFB fluids.

31.10.09

Consultant

Nephrologist WTEs

and lack of out of

hours / weekend

consultant

availability.

Appointment of 4th Nephrologist. Consultant

Nephrologist out of hours telephone advice

rota to be agreed and implemented.

Approval to appoint paperwork

for 4th Nephrologist post

progressing through required

process. Anticipate going out

to advert early November.

31.10.09

Lack of piped

oxygen and suction

in acute dialysis

area

Explore opportunities and associated costs

for installation of piped oxygen and suction

to 'high dependency' area within the unit.

Ensure compliance with daily checking

procedures for crash trolley, oxygen cylinders

and portable suction apparatus within the

unit.

Midland Medical undertaking

site survey W/C 29.10.09 to

assess feasibility of installation.

31.10.09

Documents

Services for Patients with End Stage Renal Failure at ... Shrewsbury and Telford Hospital NHS ... The systems for annual review of patients on the ... Telford patients do not have