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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
SaTH Final Renal Visit Report 2009 12.22.doc 3
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
SaTH Final Renal Visit Report 2009 12.22.doc 4
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
SaTH Final Renal Visit Report 2009 12.22.doc 5
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
SaTH Final Renal Visit Report 2009 12.22.doc 6
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.
SaTH Final Renal Visit Report 2009 12.22.doc 7
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.
SaTH Final Renal Visit Report 2009 12.22.doc 8
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.
SaTH Final Renal Visit Report 2009 12.22.doc 9
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
Warwickshire NHS Trust
Beverley Beynon-Cobb Dietitian University Hospitals Coventry and
Warwickshire NHS Trust
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
Where to go for further information, including useful
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
SaTH Final Renal Visit Report 2009 12.22.doc 11
Ref. Quality Requirement (QR) Met? Comments
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.
Where to go for further information, including useful
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.
SaTH Final Renal Visit Report 2009 12.22.doc 12
Ref. Quality Requirement (QR) Met? Comments
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.
SaTH Final Renal Visit Report 2009 12.22.doc 13
Ref. Quality Requirement (QR) Met? Comments
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
SaTH Final Renal Visit Report 2009 12.22.doc 14
Ref. Quality Requirement (QR) Met? Comments
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.
SaTH Final Renal Visit Report 2009 12.22.doc 15
Ref. Quality Requirement (QR) Met? Comments
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.
SaTH Final Renal Visit Report 2009 12.22.doc 16
Ref. Quality Requirement (QR) Met? Comments
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
SaTH Final Renal Visit Report 2009 12.22.doc 17
Ref. Quality Requirement (QR) Met? Comments
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
A protocol should be in use covering:
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.
SaTH Final Renal Visit Report 2009 12.22.doc 18
Ref. Quality Requirement (QR) Met? Comments
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.
SaTH Final Renal Visit Report 2009 12.22.doc 19
Ref. Quality Requirement (QR) Met? Comments
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
A protocol should be in use covering:
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
A protocol should be in use covering:
Frequency of haemodialysis
Duration of haemodialysis
Measurement of adequacy of haemodialysis
Pre- and post-dialysis blood sampling
Y A good protocol is available.
SaTH Final Renal Visit Report 2009 12.22.doc 20
Ref. Quality Requirement (QR) Met? Comments
70
All
A protocol should be in use covering:
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.
SaTH Final Renal Visit Report 2009 12.22.doc 21
Ref. Quality Requirement (QR) Met? Comments
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.
SaTH Final Renal Visit Report 2009 12.22.doc 22
Ref. Quality Requirement (QR) Met? Comments
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.
SaTH Final Renal Visit Report 2009 12.22.doc 23
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