The Southern Trust Experience Dr John Harty Eamon McBride - - PowerPoint PPT Presentation

‘The Southern Trust Experience’

Dr John Harty Eamon McBride Southern Health and Social Care Trust

Who Are We?

Late presentation is not a major issue for us

What makes us different?

Access to GFR trends / graphing

Electronic AKI alert system

Efficient Referral / Advice pathway

General Nephrology OPD activity

200 400 600 800 1000 1200 08/0909/1010/1111/1212/1313/1414/1515/1616/17 Virtual New

Timeline

• Agreed study in principle in Jan 16.
• Software installed but software / IT issues delayed first graphs to

August 2016.

• JH vetted all graphs subsequently selected by EMcB before

sending to GP’s.

• This process stopped in May 17 when we had major software

issues and lack of local dedicated IT support.

• Restarted graphing / medically un-vetted sending in Sept 2017

(including backlog)

Two Stage Process for Graph Selection STAGE 1

• Use the ASSIST-CKD guidelines used in the initial

training and also the more recent guidelines from ASSIST-CKD version 4 software.

• Use the GAIN guidelines for the ‘Northern Ireland

Guidelines for the Management of Chronic Kidney Disease (CKD) as well as tips picked up from Dr Harty

Phase 2: ECR check (OPD, Admissions, Referrals)

• I also check for recent hospital

admissions or bloods done in

• ther local laboratories.
• It’s especially useful in cases of

Acute Kidney Injury (AKI) to check if the GP has repeated the bloods

• r not, if a repeat has been sent

and improvement is observed I refrain from sending a graph.

• Don’t send graphs in AKI as alert

will have gone to GP

Phase 2: ECR Biochemistry

• I approach it however as a review process only, if the

decline is sustained (more than one result or steady decrease) and no obvious referral or relevant information I send a graph.

• I feel the extra check enforces the graph I am sending out

to the GP and minimises the amount of graphs which don’t

• ffer any more clinically to the patient.
• I then finalise my list and post the graphs outs keeping a

record of all the GPs who receive one for auditing purposes in the future.

Observations

• More confident in the process and the software now.
• Very important to have the local renal unit involved in

the process to monitor outcomes in the coming months and years to see if it adds to the current system in place and if and how it would fit into our current guidelines

• Again engage with the local GPs and involve them in

the process as well

DHH specific information

• Our laboratory systems have identified this patient having a

substantial fall in GFR. The red line denotes a graph has been sent to Primary care.

• If this patient is not under active follow-up by renal services please

consider discussing this patient with the Nephrology service using the Clinical Communications Gateway (CCG).

• This biochemistry data does not of course take into account this

individual person's overall health or frailty. If after review of this information provided today you feel comfortable to monitor the patient's CKD without contacting the renal team then please do so.

• For information about this service please contact Eamon McBride,

Biochemistry Department, Craigavon Hospital.Email: eamon.mcbride@southerntrust.hscni.net

Progress to date: Graphs produced

200 400 600 800 1000 1200 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 AGE 0-65, GFR=<50 AGE 65-120, GFR =<40

Progress to date: Graphs Sent to GPs

5 10 15 20 25 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 AGE 0-65, GFR=<50 AGE 65-120, GFR =<40

4% of vetted graphs are sent to GP’s

Summary: Aug 16 – April 17

5 10 15 20 25 30 35 40 45 Letter to GP No Letter Graph Sent Known Died Recovered < 65 years > 65 years

Progress Summary

• Approximately 1/3 of patients were already known to the Renal

Service

• A similar number (1/3) had clearly a reason for deterioration and

would not benefit at that point from nephrology input

– Nephrectomy – Advanced cardio-renal failure

• 31% of patients > 65 were clearly in a terminal decline and

would not benefit from referral.

• Up to 7% may benefit from referral

Final Thoughts

• ASSIST-CKD is more than a referral guide

– Encourage communication – Educational tool

• Ongoing monitoring / tests
• Re-Referral Guidelines
• Pharmacological advice
• Conservative care advice
• Like Brexit, we are moving into an uncertain time with our GP
• colleagues. ASSIST-CKD may become a key aspect of our CKD care

We have a nice view

Below are a brief overview of the guidelines from ASSIST: (LABORATORY USER GUIDE &

IT INFORMATION PACK (v4))

• Patients with a very steep eGFR graph suggest

rapidly changing renal function. This may be consistent with either acute kidney injury (AKI)

• r acute or chronic kidney disease. These

patents should be marked and a report sent to requesting clinician.

• Patients whose cumulative eGFR results are

deteriorating steadily at a significant rate (>10ml/min/year as a guide) and especially those with the latest eGFR below 30 ml/min.

• In very elderly patients a slow steady decline in

eGFR is less significant than for younger patients as the former are more likely to die of other causes before their deteriorating kidney function becomes clinically significant.

• Patients with relatively stable eGFR results in

previous years but where the decline has accelerated (>10/ml/min/year as a guide) within the last few months.

• A patient with a previous history of declining

eGFR which initially improved and then a second decline has started. Consider these as high risk and review in the second stage.

We have adopted these guidelines along with our local Northern Ireland Guidelines developed by GAIN and the Northern Ireland Nephrology Forum so a graph is sent in the following cases:

• Patients with new CKD 5 (eGFR <15

mL/min/1.73m2)

• Patients with new CKD 4 (eGFR 15-29

mL/min/1.73m2)

• Patients with:

❖ a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months ❖ a sustained decrease in GFR of 15mL/min/1.73m2 per year.

• When applying both sets of guidelines the

following are also considered : (as per GAIN)

• A sustained fall in eGFR (reduction of >15

mL/min/1.73m2) should be confirmed by repeating serum creatinine/eGFR within one month.

• Progressive CKD is usually defined by at least

three eGFRs over at least 90 days.

• Patients with CKD are referred if they have a

SUSTAINED decrease in eGFR of 15mL/min/1.73m2 per year

• A graph is sent to help identify these possible

scenarios to the GP. Highlighted differences. ✓ The southern trust already has an alert for AKI so a graph is not sent out in these cases. (unless decline sustained) ✓ If they are currently on the renal radar or have been referred as per NIECR review a graph is not sent.