Enhancing Living Kidney Donation Pathway in North Bristol Quality Improvement Team
The North Bristol Quality Improvement Team is focused on achieving more transplants in less time with a better experience through their Living Kidney Donation (LKD) pathway. They aim to streamline the pathway, reducing visits and increasing transplant rates. Initiatives include nurse-led triage appointments, optimization of specialist appointments, and improved monitoring of living donor progress with detailed spreadsheets. Additionally, the team conducts recipient workup assessments to enhance efficiency and identify areas for improvement in the transplant referral process.
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Presentation Transcript
North Bristol Quality Improvement Team Diane Evans, Transplant Coordinator Dominic Taylor, Nephrologist Samuel Turner, Transplant Surgeon
LKD pathway What are we trying to accomplish? More transplants in less time with the best experience How will we know that a change is an improvement? Shorter pathway (aiming for 18 weeks), less visits (feedback from donor survey), more transplants What changes can we make that will result in improvement? 3 visit LKD pathway
1. Nurse-led triage appt 2. Nephrologist, mGFR, CTRA 3. Surgeon, HTA, POAC PLAN ACT STUDY DO Current LK donors in assessment spreadsheet add columns and record dates from 1st August 2019 1. Merge LKD1 and LKD2 2. Thursday LKD clinics for RAR and PB alternating with 3 patients each 3. Train more IA s
New spreadsheet for monitoring living- donor progress Date LKD MDT Meeting Review One and outcome Date LKD MDT Meeting Review Two and outcome FINAL XM date (within 2 - 4 weeks of op date) NAME (DONOR) and Demogra phics NAME (RECIPIENT) and Demograph ics Radiolog y review meeting date and outcome Surgeon and Surgical appt date Date Fit to proceed - direct or KSS Desktop sign-off Date and by whom? Clinic Date Date 1st Appt HTA interview - who and Date XM results and mismatch RENAL OPA date OTHER tests required POAC Date and outcome OP DATE PLANNE D Relationship to recipient Date Q' RET GFR dateCTRA PSYCH Date COORD Desens/KSS Date MEDICAL DAY MDT REVIEW SURGICAL DAY MDT TRIAGE
Recipient Workup Aspiration 18 week target (126 days) from ODT guidance for best practice Objectives To provide a quantitative understanding of how the current referrals process is operating To identify areas of delay where we can target strategies to improve assessment To identify and discuss any variation in practice across the region Methods Retrospective review of all transplant referrals received at Southmead over 4 months from 1 September 2018 to 31st December 2018.
Nature of referrals Referral # Pre-emptive Started dialysis during ax Mean EGFR Mean BMI Mean Age Bristol 18 10 3 14.3 28 46.6 Exeter 9 7 1 14.3 27 53.3 Dorset 7 5 0 14.4 25 47.8 Gloucester 7 4 0 17.8 32 45.8 TOTAL 41 26 (63%)
Referral outcomes Referral # Added to WL Mean days from referral to WL Pending Patient factors Pending further inx/mgt Unfit / with- drawn Bristol 18 8 133 4 4 2 Exeter 9 6 97 3 0 0 Dorset 7 3 172 1 3 0 Gloucester 7 2 204 3 1 1 TOTAL 41 19 (46%) 136 11 (27%) 8 (20%) 3
Receipt and processing of referrals 90% of referrals are posted letters, 5% are emailed letters, 5 % are emails 12 DAYS 5 DAYS 17 DAYS Processed Received Written
Transplant ICE referrals Instant delivery to transplant coordinators Agreed with full nephrology team Stumbling blocks: Slow uptake Difficulty accessing completed referrals Not keen on change Presented at Transplant Steering Group NEXT: Reminders to those referring by another route Roll-out to rest of region?
Bristol Pathway 133 days 60 days 131 days 7 days Surgical Clinic (18) Waiting List (8) Renal Clinic Referral (18) MDT (10) Cardiac clinic (4) MORE INFO (5) Vasc Inx (4) ECHO/ETT +/- MPI(4) Pending (4) 10 days Clinic 34 days pre-referral 54 days for clearance 5 days EGFR >15 (1) Not fit (2) Cardiac clinic (5) ECHO/ETT +/- MPI(4) Results review (4) Clinic 84 days after referral Clinic to clearance 100 days BMI(3)
Exeter Pathway 97days 63 days 35 days 7 days Surgical Clinic (9) Waiting List (6) Renal Clinic Referral (9) MDT (6) Cardiac Inx (4) Cardiac Inx (2) MORE INFO (1) Vasc Inx (1) 32 days 105 days 5 days Cardio Clinic (3) EGFR >15 (3) 50 days
Dorset Pathway 172 days 56 days 49 days 7 days Surgical Clinic (7) Waiting List (3) Renal Clinic (7) Referral (7) MDT (5) Urology Inx (2) MORE INFO (3) Vasc Inx (1) 61 days 89 days Cardiac Inx (5) EGFR >15 (1) Nephrect omy (2) -114 days Cardio Clinic (2) Angio (1) Angio(1) Mean 79 days for clearance
Gloucester Pathway 204 days 38 days 167 days 7 days Surgical Clinic (6) Waiting List (2) Renal Clinic Referral (7) MDT (3) Vasc Inx (1) MPI (4) -72 days 73 days Clinic (1) EGFR >15 (3) With- drawn(1) Angio (1) Mean 154 days for clearance Pt Cardio(1) factor(2)
Discussion LKD Dates of clinics/investigations to be quality measures Questionnaires DROMs vs PREMs? Recipient Are we referring enough patients pre-emptively? How fixed should the eGFR <15 be for adding to MDT? For adding to WL? Should patients with BMI >35 be referred at all? To bariatric surgery first? What is the ideal timing of cardiology referral? What is the most efficient process and investigation for cardiac assessment? Pro-active chasing of outstanding referrals and investigations
Coming soon Declined deceased-donor organs used elsewhere 1 year review to inform acceptance policy Review of transplant status for pre-ESKD patients with eGFR<20
