Enhancing Living Kidney Donation Pathway in North Bristol Quality Improvement Team

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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
 
1.
Merge LKD1 and LKD2
2.
Thursday LKD clinics for RAR
and PB alternating with 3
patients each
3.
Train more IA’s
 
‘Current LK donors in
assessment’ spreadsheet –
add columns and record
dates from 1
st
 August 2019
 
New spreadsheet for monitoring living-
donor progress
 
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 outcomes
 
Receipt and processing of referrals
12 DAYS
5 DAYS
17 DAYS
 
 
90% of referrals are posted letters, 5% are emailed letters, 5 % are emails
 
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
Cardiac
clinic (4)
Vasc Inx
(4)
 EGFR
>15 (1)
10 days
133 days
60 days
  131 days
7 days
MORE
INFO (5)
5 days
Not fit
(2)
BMI(3)
Pending
(4)
ECHO/ETT
+/- MPI
(4)
Clinic 34 days pre-referral
54 days for clearance
Cardiac
clinic (5)
ECHO/ETT
+/- MPI
(4)
Clinic 84 days after referral
Clinic to clearance 100 days
Results
review (4)
 
Exeter Pathway
Cardiac
Inx (2)
Cardio
Clinic (3)
Vasc Inx
(1)
 EGFR
>15 (3)
32 days
97days
63 days
  35 days
7 days
Cardiac
Inx (4)
MORE
INFO (1)
5 days
105 days
50 days
 
Dorset Pathway
Cardiac
Inx (5)
Urology
Inx (2)
Cardio
Clinic (2)
Vasc Inx
(1)
 EGFR
>15 (1)
Nephrect
omy (2)
Angio (1)
Angio(1)
Mean 79 days for clearance
61 days
172 days
56 days
 49 days
7 days
MORE
INFO (3)
89 days
-114 days
 
Gloucester Pathway
Vasc Inx
(1)
 EGFR
>15 (3)
Mean 154 days for clearance
73 days
204 days
38 days
  167 days
7 days
Cardio(1)
MPI (4)
Clinic (1)
Angio (1)
With-
drawn(1)
 Pt
factor(2)
-72 days
 
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
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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.

  • Quality Improvement
  • Living Kidney Donation
  • Transplant Pathway
  • Bristol Team
  • Healthcare Improvement

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  1. North Bristol Quality Improvement Team Diane Evans, Transplant Coordinator Dominic Taylor, Nephrologist Samuel Turner, Transplant Surgeon

  2. 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

  3. 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

  4. 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

  5. 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.

  6. 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%)

  7. 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

  8. 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

  9. 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?

  10. 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)

  11. 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

  12. 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

  13. 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)

  14. 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

  15. 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

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