Understanding the impact of haemodialysis on UK National Health Service patients' well-being: A qualitative investigation.

AIMS AND OBJECTIVES: While haemodialysis is an effective treatment for end-stage renal disease, the requirements and restrictions it imposes on patients can be onerous. The aim of this study was to obtain UK National Health Service patients' perspectives on the challenges arising from haemodialysis with the intention of identifying potential improvements. BACKGROUND: Depression rates are particularly high in those with end-stage renal disease; however, there is limited insight into the range of stressors associated with haemodialysis treatment within the National Health Service contributing to such high rates, particularly those of a cognitive or psychological nature. DESIGN: A qualitative approach was used to obtain rich, patient-focused data; one-to-one semi-structured interviews were conducted with twenty end-stage renal disease at a UK National Health Service centre. METHODS: Patients were interviewed during a typical haemodialysis session. Thematic analysis was used to systematically interpret the data. Codes were created in an inductive and cyclical process using a constant comparative approach. RESULTS: Three themes emerged from the data: (i) fluctuations in cognitive/physical well-being across the haemodialysis cycle, (ii) restrictions arising from the haemodialysis treatment schedule, (iii) emotional impact of haemodialysis on the self and others. The findings are limited to predominantly white, older patients (median = 74 years) within a National Health Service setting. CONCLUSIONS: Several of the experiences reported by patients as challenging and distressing have so far been overlooked in the literature. A holistic-based approach to treatment, acknowledging all aspects of a patient's well-being, is essential if optimal quality of life is to be achieved by healthcare providers. RELEVANCE TO CLINICAL PRACTICE: The findings can be used to inform future interventions and guidelines aimed at improving patients' treatment adherence and outcomes, for example, improved reliable access to mental health specialists.

Learning leadership skills in practice through quality improvement.

The development of leadership skills in doctors in training is essential to support both their professional development and the future supply of clinical leaders the NHS so desperately needs. There is, however, limited opportunity in current training programmes for trainees to learn and develop these skills, and what opportunity there is has often focused on management rather than leadership skills. Involvement in trainee-led supported quality improvement projects can teach these skills. We summarise the current limitations in leadership training and discuss how the College's 'Learning To Make a Difference' programme, and others like it, are helping to teach leadership.

Effect of buttonhole cannulation with a polycarbonate PEG on in-center hemodialysis fistula outcomes: a randomized controlled trial.

BACKGROUND: Quality improvement strategies to increase and maintain the numbers of arteriovenous fistulas (AVFs) are a critical drive in enhancing the quality of care of patients receiving treatment with hemodialysis. How the AVF is needled is an important consideration in AVF survival; the ideal cannulation technique has not been established to date. STUDY DESIGN: Prospective randomized single-center trial. SETTING & PARTICIPANTS: Patients on maintenance hemodialysis therapy (N = 140). INTERVENTION: A 1-year intervention of buttonhole (constant site) or usual-practice (different site) cannulation. OUTCOMES: Primary study outcome was AVF survival over 1 year, in which AVF failure was defined as an AVF no longer used for hemodialysis (also referred to as assisted patency). Secondary outcomes included primary patency, number of access interventions, bleeding time, infection rate, cannulation time and pain, and aneurysm formation. RESULTS: Demographic data were similar for both groups. The primary outcome measure of AVF survival at 1 year was statistically significantly increased in the buttonhole group (100% vs 86% with usual practice; P = 0.005, log-rank test). In the buttonhole group, there were fewer interventions (19% vs 39% in usual practice) and less existing aneurysm enlargement (23% vs 67% in usual practice). There were no bacteremia events in the buttonhole group and 2 in the usual-practice group (0.09/1,000 AVF days). There were no significant differences in bleeding times and lignocaine use between the 2 groups. LIMITATIONS: A single-center study, lack of blinding. CONCLUSIONS: In this study, AVF survival was significantly greater when using buttonhole cannulation. The buttonhole technique significantly decreased the need for access interventions and reduced existing aneurysm enlargement. Concerns of increased infection rates or prolonged bleeding times with the buttonhole technique were not seen in this study. The buttonhole technique should be considered the cannulation technique of choice for AVFs.

Learning to make a difference: introducing quality improvement methods to core medical trainees.

The 'Learning To Make a Difference' (LTMD) initiative was a Royal College of Physicians/Joint Royal Colleges of Physicians Training Board collaboration supported by The Health Foundation. It aimed to support the learning and development of new and relevant skills in quality improvement (QI) methodology by trainees to enable them to deliver effective QI projects at the frontline. Core medical trainees in five deaneries were offered the opportunity to undertake a QI project in place of a mandatory clinical audit during 2010-2011. In total, 61 trainees completed 46 QI projects. Evaluation of the project outcomes demonstrated the acceptability, feasibility and strengths of trainee-led small-scale change and how this can deliver improvement in the quality of multidisciplinary working, clinical practice and patient care. The LTMD project supports the further development and spread of this approach, encouraging all physician trainees, and their supervisors, to understand, develop and embed appropriate skills in QI methodology as part of their professional role. In addition, the project has identified the necessary infrastructure to enable this to happen.

Use of real-time ultrasound guidance for the placement of hemodialysis catheters: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Insertion of percutaneous hemodialysis catheters is an invasive procedure with a small but definite risk of morbidity and mortality. OBJECTIVES: Assessing potential benefits of using real-time 2-dimensional Doppler ultrasound imaging guidance for the insertion of hemodialysis catheters compared with insertion based solely on anatomic landmarks. STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials. DATA SOURCES: MEDLINE (1966 to July 2010), EMBASE (1980 to July 2010), Cochrane Renal Group Specialised Register, and Cochrane Central Register of Controlled Trials (CENTRAL). SETTING & POPULATION: Patients requiring hemodialysis catheter insertion. SELECTION CRITERIA FOR STUDIES: We included all randomized controlled trials regardless of publication status or language. INTERVENTIONS: Real-time 2-dimensional Doppler ultrasound image guidance. OUTCOMES: Catheter placement failures, catheters failed to be placed in the first attempt, attempts per catheter inserted, time taken for successful venous puncture, and complications (carotid artery puncture, pneumo- or hemothorax, neck hematoma, and brachial plexus injury). Treatment effects were summarized with the RR measure for dichotomous outcomes and mean difference for continuous outcomes. RESULTS: 7 trials with 830 catheters were identified. Ultrasound guidance significantly decreased the risk of the following outcomes: catheter placement failure (7 studies, 830 catheters; RR, 0.12; 95% CI, 0.04-0.37), failure to place catheter on first attempt (5 studies, 595 catheters; RR, 0.40; 95% CI, 0.29-0.56), arterial punctures (6 trials, 785 catheters; RR, 0.22; 95% CI, 0.06-0.81), and hematoma formation (4 trials, 323 catheters; RR, 0.27; 95% CI, 0.08-0.88). It also significantly decreased the time to cannulate the vein (1 trial, 73 catheters; mean difference, -1.40; 95% CI, -2.17 to -0.63), and number of attempts per catheter insertion (1 trial, 110 catheters; mean difference, -0.35; 95% CI, -0.54 to -0.16). LIMITATIONS: Only 7 studies were identified, of which 3 were reported in only a conference abstract form. Some outcomes were reported in only 1 study. CONCLUSIONS: Use of real-time Doppler ultrasound guidance has benefits with respect to several important clinical outcomes, and its routine use in the insertion of hemodialysis catheters is strongly recommended.

Ultrasound use for the placement of haemodialysis catheters.

BACKGROUND: A significant proportion of patients starting dialysis do so with a temporary or tunnelled haemodialysis catheter. Insertion of these catheters can be achieved either by using the anatomical landmarks for the veins into which they are inserted or using ultrasound guidance. It has been suggested that the use of ultrasound guidance reduces the immediate complications of haemodialysis catheter insertions such as pneumothorax or arterial puncture. OBJECTIVES: The aim of the review was to compare the use of real-time 2-dimensional (2-D) Doppler ultrasound venous imaging in the insertion of percutaneous central venous catheters for dialysis versus the traditional "blind" landmark method. SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL). Reference lists of identified studies and relevant narrative reviews were also screened. Search date: January 2011. SELECTION CRITERIA: All randomised controlled trials (RCTs) and quasi-RCTs evaluating ultrasound guidance in the percutaneous insertion of central venous catheters for dialysis (both cuffed and uncuffed) against the traditional blind landmark method. DATA COLLECTION AND ANALYSIS: Two authors assessed risk of bias and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI). MAIN RESULTS: We identified seven studies enrolling 767 patients and with 830 catheter insertions. Three of seven studies described the method of random sequence generation, none described allocation concealment, and blinding of participants and personnel was not possible. Real-time ultrasound guidance was found to significantly reduce the risk of catheter placement failure on the first attempt (5 studies, 595 catheters): RR 0.40, 95% CI 0.30 to 0.52), significantly reduce the risk of arterial puncture (6 studies, 535 catheters: RR 0.13, 95% CI 0.04 to 0.37) and haematomas (4 studies, 323 catheters: RR 0.22, 95% CI 0.06 to 0.81) when compared to the landmark method. The time taken for successful cannulation was significantly lower with the use of real-time ultrasound guidance (1 study, 73 catheters: MD -1.40 min, 95% CI -2.17 to -0.63) and there were less attempts/catheter insertion (1 study, 110 catheters: -0.35, 95% CI -0.54 to -0.16). AUTHORS' CONCLUSIONS: Use of real-time 2-D Doppler ultrasound guidance has significant benefits with respect to the number if catheters successfully inserted on the first attempt, reduction in the risk of arterial puncture and haematomas and the time taken for successful vein puncture.

Electronic alerts for acute kidney injury across primary and secondary care.

PROBLEM: In 2009 the National Confidential Enquiry into Patient Outcome and Death suggested only 50% of patients with acute kidney injury (AKI) receive good standards of care. In response National Health Service (NHS) England mandated the use of electronic AKI alerts within secondary care. However, we recognised AKI is not just a secondary care problem, where primary care has a crucial role to play in prevention, early detection and management as well as post-AKI care. METHODS: AKI alerts were implemented in primary and secondary care services for a population of 480 000. Comparisons were made in AKI incidence, peak creatinine following AKI and renal recovery in the years before and after using Byar's approximation (95% CI). INTERVENTION: A complex quality improvement initiative was implemented based on the design and integration of an AKI alerting system within laboratory information management systems for primary and secondary care, with an affixed URL for clinicians to access a care bundle of AKI guidelines on safe prescribing, patient advice and early contact with nephrology. RESULTS: The intervention was associated with an 8% increase in creatinine testing (n=32 563). Hospital acquired AKI detection increased by 6%, while community acquired AKI detection increased by 3% and AKI stage 3 detected in primary care fell by 14%. The intervention overall had no effect on AKI severity but did improve follow-up testing and renal recovery. Importantly hospital AKI 3 recoveries improved by 22%. In a small number of AKI cases, the algorithm did not produce an alert resulting in a reduction in follow-up testing compared with preintervention levels. CONCLUSION: The introduction of AKI alerts in primary and secondary care, in conjunction with access to an AKI care bundle, was associated with higher rates of repeat blood sampling, AKI detection and renal recovery. Validating accuracy of alerts is required to avoid patient harm.

A potential barrier to adherence? Memory for future intentions is impaired in hemodialysis patients.

INTRODUCTION: End-stage renal disease (ESRD) has been associated with a range of cognitive deficits, including impaired retrospective memory and attention. Prospective memory (PM) is memory for future intentions, such as remembering to take medication on time. Prospective memory has not been examined in any ESRD patients; yet, the implications upon diet and medication management could potentially have detrimental effects on patient welfare. This is the first study to examine PM in ESRD patients being treated with hemodialysis (HD). METHODS: Hemodialysis patients (n = 18) were compared with age-matched and education-matched controls (n = 18) on a boardgame task that emulates a typical week of activities (i.e., grocery shopping, meetings with friends), requiring the participant to remember a series of upcoming tasks. Other measures were also examined, including general cognitive decline, measures of independent living, IQ, and mood. FINDINGS: Patients recalled significantly fewer upcoming events than the control group, suggesting an impairment of PM. No significant relationship was found between PM performance and any other measures, suggesting the difference between groups is likely due to the effects of ESRD, HD treatment, or some associated comorbidity. DISCUSSION: This is the first study to demonstrate a PM deficit in patients undergoing HD treatment. This finding contributes to the current knowledge of the cognitive profile of patients undergoing HD while also highlighting the implications that a PM deficit may have on patient quality of life. The finding may go some way to explaining variances in patients' ability to monitor and adhere to medication and dietary regimes and, ultimately, to live independently. The study also highlights the necessity of viewing treatment for ESRD as a holistic process to maximize patient well-being.

Building the Bridge to Quality: An Urgent Call to Integrate Quality Improvement and Patient Safety Education With Clinical Care.

Current models of quality improvement and patient safety (QIPS) education are not fully integrated with clinical care delivery, representing a major impediment toward achieving widespread QIPS competency among health professions learners and practitioners. The Royal College of Physicians and Surgeons of Canada organized a 2-day consensus conference in Niagara Falls, Ontario, Canada, called Building the Bridge to Quality, in September 2016. Its goal was to convene an international group of educational and health system leaders, educators, frontline clinicians, learners, and patients to engage in a consensus-building process and generate a list of actionable strategies that individuals and organizations can use to better integrate QIPS education with clinical care.Four strategic directions emerged: prioritize the integration of QIPS education and clinical care, build structures and implement processes to integrate QIPS education and clinical care, build capacity for QIPS education at multiple levels, and align educational and patient outcomes to improve quality and patient safety. Individuals and organizations can refer to the specific tactics associated with the 4 strategic directions to create a road map of targeted actions most relevant to their organizational starting point.To achieve widespread change, collaborative efforts and alignment of intrinsic and extrinsic motivators are needed on an international scale to shift the culture of educational and clinical environments and build bridges that connect training programs and clinical environments, align educational and health system priorities, and improve both learning and care, with the ultimate goal of achieving improved outcomes and experiences for patients, their families, and communities.

HIV-related admissions to a district general hospital in the U.K.: a single centre study.

This study evaluates the patient and disease characteristics, potential cost implications and short-term outcomes of 64 adult patients admitted with HIV-related illnesses. The majority (65.6%) were black Africans and 75% were immigrants to the U.K. Of the 64 patients, 61% were unaware of their HIV status at admission; 50% had CD4 count <50 cells/microl and 48% had viral load >10(5) copies/ml. Thirty-eight patients had AIDS and this accounted for 66% of the total 897 inpatient days (equivalent to 16.5-30.2 patient years of highly active antiretroviral therapy (HAART), depending on the type of HAART regimen used). Fifteen (23.8%) died in hospital, and of these 11 had AIDS and a CD4 count <200 cells/microl. Immigrants from countries of high prevalence accounted for the majority of the inpatient HIV caseload. They presented late and had high in-hospital mortality. Screening programmes to allow early diagnosis and treatment should be adapted to reach migrant populations.

Percutaneous fluoroscopically guided placement of peritoneal dialysis catheters--a 10-year experience.

Peritoneal dialysis (PD) catheters maybe inserted surgically or percutaneously. Since 1997, 209 patients in our unit have had a PD catheter inserted percutaneously with fluoroscopic guidance. Data on all these PD catheters were collected prospectively on a PROTON computer database. 5/209 (2.4%) insertion attempts were abandoned. 204 catheters were successfully placed giving an initial technical success of 97.6%. 200/204 catheters were used for dialysis. 13/200 (6.5%) catheters developed early exit site infections; 12/13 were successfully treated and dialysis proceeded uneventfully. 3/200 (1.5%) catheters developed early peritonitis; 1/3 was removed as antibiotic treatment was unsuccessful. 10/200 (5%) catheters developed an early leak; 2/10 did not resolve with conservative therapy and were removed. 14/200 (7%) catheters did not allow sufficient fluid entry for PD; all 14 had migrated out of the pelvis and were removed. In total, 18/200 (9%) catheters were removed in the first 2 months due to these early complications. The remaining 182/200 (91%) were fully functional for PD. Technical survival (excluding patient death with a functioning catheter and successful kidney transplantation) at 1, 2, and 5 years was 77%, 61%, and 31%, respectively. Our 10 year experience of PD catheters inserted percutaneously with fluoroscopic guidance demonstrates a high technical success and a low complication rate. The data presented may be used as the standard for this technique.

Sustainability in quality improvement: redefining value.

Sustainability can be considered a domain of quality in -healthcare, extending the responsibility of health services to patients not just of today but of the future. The longer term -perspective highlights the impacts of our healthcare system on our environment and communities and in turn back onto population health. A sustainable approach will therefore expand the healthcare definition of value to measure health outcomes against environmental and social impacts alongside financial costs. We set out a practical framework for including these new dimensions in an already well-defined model of quality improvement. This has the potential to harness the growing quality improvement movement to shape a more sustainable health service, while improving patient outcomes. Early experience suggests that the new model may also provide immediate -benefits, including additional motivation for clinicians to engage in quality improvement, directing their efforts towards high value interventions and enabling capture and communication of a wider range of impacts on patients, staff and communities.

Sustainability in quality improvement: measuring impact.

'Sustainable value' considers patient and population outcomes against environmental, social and economic costs or impacts, providing a framework for driving sustainable improvements in healthcare for current and future generations. Measuring the impact of a quality improvement initiative on sustainable value is a new endeavour. For this to be both meaningful and useful, we must balance academic rigour (using a reproducible methodology to capture the most relevant and important impacts) against pragmatism (working within the constraints of available time and data). Using case studies, we discuss how the different variables of sustainable value may be measured in practice.

Improving the completeness of acute kidney injury follow-up information in hospital electronic discharge letters.

OBJECTIVES: Acute kidney injury (AKI) is common in hospitalised patients, often mandates changes to regular medications and can be unresolved at hospital discharge. General practitioners (GPs) require apposite AKI-related information in electronic discharge letters (EDLs). In 2015 NHS England introduced a care quality standard that all EDLs should include four items of information for patients with AKI. We performed a 12-month quality improvement project (QIP) aimed at achieving above 90% compliance with the quality standard. METHODS: Hospital-wide episodes of AKI were detected using the nationally approved electronic AKI alerts system. 25 patient AKI episodes were audited per month for 12 months using the electronic patient record. The target compliance rate was staggered at 35%, 65% and 90% for each subsequent 3-month block. Baseline compliance was 22%. Measures taken to improve compliance included email information, grand rounds, ward-level meetings, computer screensavers, nurse support, clinical governance meetings, and face-to-face rapid education. Annotation of AKI within the computer EDL system was progressively enhanced such that in the final quarter the presence of an AKI-alert mandated the user to complete the AKI annotation before the EDL could be signed off. RESULTS: The completion rate improved to 37% in the second quarter, 51% in the third quarter and 92% in the fourth quarter. This change has been sustained in the 14 months since. CONCLUSIONS: By the end of the study, omissions relating to AKI information were reduced from 78% to less than 10%, indicating our QIP was highly effective-meeting the quality standard. The single most important factor in improving documentation was to mandate user review of AKI aftercare in patients with electronic AKI alerts. Our study encompassed hospital-wide inpatients, and our results could be replicated at other acute hospitals that have implemented an EDL system connected to an AKI alert system.

The predictive validity of a situational judgement test, a clinical problem solving test and the core medical training selection methods for performance in specialty training .

The aim of this study was to follow up a sample of physicians who began core medical training (CMT) in 2009. This paper examines the long-term validity of CMT and GP selection methods in predicting performance in the Membership of Royal College of Physicians (MRCP(UK)) examinations. We performed a longitudinal study, examining the extent to which the GP and CMT selection methods (T1) predict performance in the MRCP(UK) examinations (T2). A total of 2,569 applicants from 2008-09 who completed CMT and GP selection methods were included in the study. Looking at MRCP(UK) part 1, part 2 written and PACES scores, both CMT and GP selection methods show evidence of predictive validity for the outcome variables, and hierarchical regressions show the GP methods add significant value to the CMT selection process. CMT selection methods predict performance in important outcomes and have good evidence of validity; the GP methods may have an additional role alongside the CMT selection methods.

Stereopsis in end-stage renal disease (ESRD).

We investigated an effect of end-stage renal disease (ESRD) on the visual system by measuring the ability of 21 patients to perceive depth in the random dot stereograms and circles of the Randot Test. To control for other factors which might influence performance on the tests of stereopsis, patients were compared with healthy controls matched for age, years of education, IQ, and general cognitive ability. Vernier acuity (thought to reflect mainly central processing) and Landolt acuity (more sensitive to retinal and optical abnormalities) were also measured, but the study did not include a formal ophthalmological examination. All controls could perceive depth in random dot stereograms, whereas 9/21 patients could not. Patients who could perceive depth had worse stereoacuity than did their matched controls. The patient group as a whole had worse Vernier and Landolt acuities than the controls. The stereoblind patient subgroup had similar Vernier acuity to the stereoscopic subgroup, but worse Landolt acuity, and was more likely to have peripheral vascular disease. We conclude that ESRD had affected structures both within the eye, and within the visual brain. However, the similarity of Vernier acuity and difference of Landolt acuity in the stereoblind and stereoscopic patient subgroups suggest that the differences in stereoscopic ability arise from abnormalities in the eyes rather than in the brain.

Fungal peritonitis complicating peritoneal dialysis: report of 18 cases and analysis of outcomes.

Fungal peritonitis is a significant cause of morbidity and mortality in patients undergoing peritoneal dialysis (PD). This retrospective study evaluated patients with fungal peritonitis in our dialysis unit from December 1999 through September 2003. We analyzed the demographic and clinical characteristics of patients to identify possible risk factors. Main clinical outcomes of interest were technique survival and mortality. During the study period, 18 patients were diagnosed with fungal peritonitis (15 on continuous ambulatory PD, 3 on automated PD). Fungal peritonitis accounted for 6% of all peritonitis episodes during the study period. Candida species were the infecting organism in 15 patients (83%). All 18 patients received antifungal treatment according to the International Society of Peritoneal Dialysis (ISPD) recommendations that were current during the study period. Two patients (11%) died with the PD catheter in situ, and 1 patient died after dialysis was withdrawn because of deterioration in other comorbid conditions. All the surviving patients were switched to hemodialysis. Of the 18 patients, 15 (83%) had history of antibiotic treatment for bacterial peritonitis within the 4 weeks preceding the fungal peritonitis episode. Our study provides further support for the current ISPD recommendation that the PD catheter should be removed as soon as a diagnosis of fungal peritonitis is made in a patient.

Training healthcare professionals in quality improvement.

The Academy of Medical Royal College's report Quality improvement - training for better outcomes sets a path for the normalisation of quality improvement as part of all health professionals' jobs. This accompanies similar calls to action by the King's Fund and the Faculty of Medical Leadership and Management and is aligned with NHS Improvement and Health Education England future strategies. These exhortations to action come on the backdrop of increased fiscal constraints within the NHS, low morale, a burgeoning volume of research evidence and audit outputs and increasing complexity of how we deliver care in a bewildering NHS landscape. Asking the question 'how can we do something better?' or 'do we really need to do this?', and building our resilience and capability to respond effectively gives us new purpose, the right skills and a means to influence and make a difference to the safety, -effectiveness and experience of patient care. Most importantly, we do this through harnessing the talents of -multiprofessional teams - with meaningful patient involvement - to rediscover the joy and optimism in our work and what truly motivates us and to see this translated into improved sustainable outcomes for our patients and our working days.