cdha renal program - nova scotia health...

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CD

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Capital District Health Authority

Queen Elizabeth II Health Sciences

Centre

Room 606 Dickson Building

1276 South Park Street

Halifax, Nova Scotia

Canada

B3H 2Y9

Phone: (902) 473-7545

Fax: (902) 473-4168

www.cdha.nshealth.ca/renal-program

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Table of Contents

Executive Summary …………………………………………………………..……….……….3

Acknowledgments …………………………………………………………….……….…….…4

Program Statistics …………………………………………………………………….….…….5

Renal Clinic Statistics …....…………………………………………….……………………..12

Home and Satellite Dialysis Unit Statistics ……………………………..………….………..14

In-Centre Hemodialysis Unit Statistics……………………………………….……………….16

Balanced Scorecard ………………………………………………….…………...……….…..21

Accreditation 2013 ……………………………………………………..………….…………..22

Research ………………………………………………...…………...………………….……..22

Initiatives ………………………………………………………………..……………………..26

Quality Care Teams …………………………………………………….…………………….32

Directions/Priorities for future planning ……………………………….…………….……..38

Addendum A: EPO Costs for In-Centre QEII and DGH Hemodialysis.…...…………..….40

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Executive Summary

The Capital District Health Authority (CDHA) Renal Program‟s vision of „Innovative Quality Renal

Care‟ is achieved through its mission statement of „working with the health care system, its partners,

patients and families to achieve optimal integrated care through advocacy, education, research, and

leadership. The Renal Program offers many services at many different service locations. Included are the

Renal Clinic, Home and Satellite Dialysis Unit, and the in-centre hemodialysis units in Halifax at the

Dickson centre, and at the Dartmouth General Hospital (DGH). The program operates in a

multidisciplinary fashion with nephrologists, nurse practitioners, registered nurses, licensed practical

nurses, dieticians, social workers, Information Technology (IT) support, clerical support, biomedical

technicians, a vascular access nurse, and Peritoneal Dialysis (PD) access nurse. The Renal program

maintains strong relationships with Inpatient Nephrology, Multi Organ Transplant Program (MOTP),

Victorian Order of Nurses (VON) and Continuing Care, Interventional Radiology, Vascular Surgery,

General Surgery, The Nova Scotia Renal Program, and the Cape Breton, Yarmouth, and Prince Edward

Island (PEI) Renal Programs.

The multidisciplinary Renal Clinic receives outpatient nephrology consultations, provides appointments

with nephrologists and nurse practitioners, and offers pre-dialysis education sessions and small group

education sessions. Key focus areas in the renal clinic are health promotion, slowing the progression of

renal disease, and supporting patients in their decision-making process if they need to start a renal

replacement therapy.

The Home Dialysis and Satellite Unit supports patients and their families to dialyze in the comfort and

convenience of their own owns after completing education and training in the home dialysis unit. For

patients performing PD or home hemodialysis (HHD) in their own homes, there is 24 hour on-call support

from an RN. Also, the home dialysis and satellite dialysis unit operates small rural dialysis units in

Berwick, Liverpool, Pictou, Port Hawkesbury, Sherbrooke, Springhill, and Truro. The unit also operates

in conjunction with Guysborough Antigonish Strait Health Authority (GASHA) with the Antigonish

dialysis unit. Key focus areas in the home and satellite dialysis unit are to maximize self-management

through home therapies, and keeping people in their communities through home dialysis and rural dialysis

units.

The in-centre hemodialysis units in the Dickson and DGH provide a large proportion of dialysis

treatments in the CDHA region. The Dickson in-centre hemodialysis unit provides fallback support for

the rest of the renal program, acute dialysis treatments off-unit in ICU, IMCU, or ERs, as well as support

to other renal programs in the Maritimes including Yarmouth, Cape Breton, PEI, New Brunswick, and

Newfoundland.

The Renal Program strives for quality, and as such has many different quality teams that each focus on

improving the safety and quality that is delivered. The Renal Program is also committed to improving

the quality of renal care and is actively involved in the research community.

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Finally, the renal program is looking towards the future with the creation of the Renal Palliation

And Therapeutic Harmonization (PATH) clinic, the promotion of home therapies, and the

transitioning of satellite dialysis units to the local health authorities in which they are located.

Matt Phillips RN BScN; Nephrology Quality Leader

Acknowledgments

This report would not have been possible without the support and contributions of many dedicated and

talented individuals in the renal program and beyond. It would not be possible to individually

acknowledge all those who assisted or contributed to the development of this report, but the following

deserve special mention. Special thanks go to the Renal Program Quality and Patient Safety Team for

developing the framework for this Annual Report, and also to Dr Steven Soroka and Cynthia Stockman

for on-going guidance and support. Thanks goes to the committee chairs of each quality team for

submitting on behalf of their respective teams their annual reports. Statistics were provided by Niall

Sheehy and Avtar Seerha, the renal program systems analysts, as well as Nancy MacDonald from STAR

Reporting, Denise Harrie, Paula Mossop, and Cindy Everett. Research information was provided by

Susan Fleet, David Landry NP, Dr. Jo-Anne Wilson and Dr. Michael West. Initiatives information was

provided by Michelle Jensen, David Landry, Paula Mossop, Cynthia Stockman, Sohani Welcher, and Dr.

Jo-Anne Wilson.

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Program Statistics

The Renal Program has developed a database, ‘My Nephrology’ and collects an abundance of

data. The program uses this data for program reporting, accreditation requirements,

organizational reporting, provincial reporting, and research purposes. The program has invested a

significant amount of time, energy, and resources in developing and implementing „My

Nephrology‟, a robust, quality database. The program is continually improving the quality of the

data in the database, as well as the capabilities of the database. The majority of the data

displayed in this report comes from „my nephrology‟, however, other databases are used as well

by the program including: STAR (Patient processing system); Pathways Healthcare Scheduling

system (PHS); Various unit-specific Microsoft access databases; Canadian Organ Replacement

Registry (CORR) databases; and, SAP. Unless indicated otherwise, all data presented is for the

2011 Fiscal year, April 1 2011- March 31, 2012.

**My Nephrology database was showcased at the 2012 CDHA Quality Week Poster Fair for its

contribution to the development of a nutritional panel and nutritional report card for dialysis patients.

Distribution of Modalities

As noted, the renal program offers support for patients to dialyze in their own homes with either PD or

HHD, in Rural Satellite Dialysis Units, or in one of the two in-centre hemodialysis units in the Halifax

Regional Municipality (HRM). Below is a representation of the distribution of modalities in the program.

246112

5917

Distribution of Modalitieson March 31, 2012

In-Centre Hemodialysis (56.6%)

Satellite Hemodialysis (25.8%)

PD (13.5%)

HHD (3.9%)

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Dialysis Trends

In-Centre Satellite PD HHD Total

2011 246 (56.6%) 112 (25.8%) 59 (13.5%) 17 (3.9%) 434

2010 242 (58.7%) 90 (21.8%) 66 (16%) 14 (3.3%) 412

2009 229 (54.9%) 90 (21.6%) 87 (20.9%) 11 (2.6) 417

2008 242 (58.6%) 89 (21.5%) 77 (18.6%) 5 (1.2%) 413

All figures are snapshots of the last day of each fiscal year (eg. 2011 is the data from March 31, 2012)

Number of Incident Patients in 2011

Incident dialysis patients are defined using their initial renal replacement therapy. This table does not

capture changes of modality (Hemodialysis PD, or TransplantHemodialysis).

Q1 Q2 Q3 Q4 Total

In-Centre 25 24 17 14 80

PD 5 7 3 9 24

Home

Hemodialysis

0 0 0 2 2

Total 30 31 20 25 106

0

50

100

150

200

250

300

2008 2009 2010 2011

In-Centre

Satellite

PD

HHD

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Number of Program Separations

Reason for Separation Number

Death 63

Transplant* 35*

Stopped Treatment 19

Recovered Function 7

Transferred to Another

Program

5

Total Program

Separations

129

* This is the number of CDHA chronic dialysis patients who received a kidney transplant, and not the

total number of kidney transplants performed at CDHA.

Number of Hemodialysis Treatments Performed

Total number of hemodialysis treatments performed by the renal program. This does not include

home hemodialysis treatments independently performed by patients in their own homes.

Treatment Location Number of HD treatments performed

Dickson In-centre unit 34 056

DGH In-Centre Unit 7 094

Satellite Dialysis units 15 816

Home Dialysis Unit 107

Acute Hemodialysis ICU/IMCU/ER 910

Total Hemodialysis Treatments 57 983

Prevalence of Vascular Access

It is well documented that the Arteriovenous Fistula (AVF) has the best outcomes for the

indicators of infection, adequate dialysis clearance, and mortality. Despite AVF‟s having better

overall outcomes than central venous catheters (CVC‟s), a CVC may be more appropriate for

individual patients based on many factors including: co-morbidities including peripheral vascular

disease (PVD) and diabetes; clinical frailty; multiple unsuccessful AVF creation attempts; or,

patient preference. The Renal Program is very conscious of appropriate individualized care, so

while AVF‟s are correlated with better patient outcomes, the program understands that AVF‟s

for all patients is not always appropriate. The increase in prevalence of CVC is due to many of

the factors identified above and is generally indicative of an older, more frail population on

dialysis.

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Vascular Access Related Interventions

The renal program through the vascular access nurse has developed a strong working relationship with

both vascular surgery and interventional radiology. These strong relationships have been essential in

providing safe, seamless, appropriate access-related care and interventions to the almost 400 patients on

hemodialysis. A table is provided below that provides a snapshot of the extent the renal program interacts

with both vascular surgery as well as interventional radiology.

Vascular Access Surgery

Referrals sent for Vascular

Access Surgery

150

Vascular Access Surgeries

Performed*

107

* Vascular access surgeries include AVF creations, revisions, and ligations.

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Interventional Radiology (IR) Procedures

Tunneled CVC Line Insertions 115

Tunneled CVC Line Exchanges 131

AVF De-clots 5

Fistulograms 137

Fistolplasties 88

Total IR Procedures 476

Medication Usage in the Renal Program

Dickson Centre

Drug $ Trending in Hemodialysis Unit 2006-2012

DRUG 2006-2007 2007-2008 2008-2009 2009-

2010 2010-2011 2011-2012

Alteplase $264,331 $333,312 $326,278 $397,254 $374,720 $378,240

Sodium Thiosulfate $157,539 $173,344 $97,328 $358,446 $140,306 $88,664

Iron Dextran $55,042 $60,000 $64,144 $54,844 $65,520 $73,965

Iron Sucrose $44,025 $54,188 $79,238 $75,150 $69,525 $56,888

Sodium Citrate $0 $0 $0 $31,158 $46,402 $53,799

Heparin $73,228 $76,868 $75,929 $34,345 $32,325 $37,606

Danaparoid $17,233 $24,783 $30,777 $2,359 $13,365 $11,990

Calcitriol $8,041 $8,806 $15,682 $12,258 $9,274 $4,637

Dartmouth In-Centre

Drug $ Trending in DGH Hemodialysis Unit 2006-2012

DRUG 2006-

2007

2007-

2008

2008-

2009

2009-

2010

2010-

2011

2011-

2012

Alteplase $8,001 $20,032 $60,736 $70,592 $65,024 $57,152

Calcitriol $774 $2,322 $5,169 $5,255 $4,031 $2,108

Heparin $6,479 $8,294 $15,033 $6,322 $4,525 $2,894

Iron Dextran $8,704 $8,850 $7,460 $8,921 $9,740 $14,411

Iron Sucrose $13,125 $21,375 $31,088 $29,812 $23,775 $18,075

Sodium Citrate $0 $0 $0 $3,831 $6,591 $6,449

Sodium Thiosulfate $8,602 $43,471 $49,097 $5,839 $0 $0

Please note: EPO usage and costs were not included in the original annual report posted to the public

CDHA website on September 7, 2012. EPO usage and costs have been added to the annual report as

Addendum A on September 13, 2012.

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Medication Cost Comparison between Dickson Centre and DGH

Drug Costs in Hemodialysis Units at CDHA 2006-2012

Unit Location 2006-

2007

2007-

2008

2008-

2009 2009-2010

2010-

2011

2011-

2012

DICKSON $651,463 $774,431 $719,033 $1,205,459 $832,377 $742,174

DGH $56,620 $124,446 $179,603 $138,843 $118,570 $106,998

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012

Drug Costs in Hemodialysis Units at CDHAQEII

DGH

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Medication Usage in DGH In-Centre

Medication Usage in Dickson Centre 2006-2011

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

Alteplase Calcitriol Heparin Iron Dextran

Iron Sucrose

Sodium Bicarbonate

Sodium Citrate

Sodium Thiosulfate

Top $ Drugs in DGH Hemodialysis Unit2006-2007

2007-2008

2008-2009

2009-2010

2010-2011

2011-2012

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000

$450,000

Alteplase Sodium Thiosulfate Iron Dextran Iron Sucrose Sodium Citrate

Top 5 Drugs in QEII Hemodialysis 2006-2007

2007-2008

2008-2009

2009-2010

2010-2011

2011-2012

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Renal Clinic Statistics

The Renal Clinic follows patients with Chronic Kidney Disease (CKD) not yet on dialysis. The

Multidisciplinary clinic provides care for new referrals with CKD, maintenance care for patients

with CKD, group teaching sessions and one on one teaching sessions, when appropriate.

Referrals to the Renal Clinic

All Referrals received by the renal clinic are assessed by a nephrologist, and assigned a level of

urgency, based on the information provided with the assessment. Levels of urgency, or priority

targets, are as follows:

P1: Seen by a nephrologist within 7 days

P2: Seen by a nephrologist within 1 month

P3: Seen by a Nephrologist within 3 months

P4: Seen by a nephrologist within 1 year

Referrals to the Renal Clinic

Priority/

Quarter

P1 P2 P3 P4 Total

Q1 14 79 114 21 228

Q2 20 73 135 46 274

Q3 13 75 112 50 250

Q4 18 66 146 44 274

Total 65 293 507 161 1026

New Visits to the Renal Clinic

This table is a representation of patients who attend the renal clinic for the first time.

Q1 Q2 Q3 Q4 Total

P1 14 19 12 16 61

P2 83 82 63 71 299

P3 55 79 167 101 402

P4 0 0 2 27 29

Total 152 180 244 215 791

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Appointments in the Renal Clinic

Total Number of Visits to Nephrologists (new and returning) 3604

Total Number of Visits to Nurse Practitioners (new and returning) 387

Total Number of Visits to Renal Dietician 417

Total Number of Visits for Education Classes 219

Total Number of Visits for 1:1 Nursing Assessments or teaching 291

Total Number of Visits to Research Nurse 20

Total Number of Visits (attending not specified) 149

Total Number of Visits to Renal Clinic 5087

PD Catheter Surgeries

New PD Catheter Insertions 39

PD Catheter Removals 23

PD Catheter Exchanges 3

PD Catheter Repositionings 2

Total PD Catheter Surgeries 67

PD Average Wait Times

The PD access nurse tracks and reports all consults for PD catheters and PD catheter insertions. Below is

the average wait time for „consult to clinic‟ as well as „clinic to OR‟ Q1 2008 to Q1 2012.

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Home and Satellite Dialysis Unit Statistics

The Home and satellite dialysis unit provides education, training and support for patients who

manage their own dialysis treatments, either peritoneal dialysis or hemodialysis, in their home.

After training, the unit provides 24 hour on-call support for all dialysis-related issues with all

home dialysis patients. The home dialysis unit also oversees seven satellite dialysis units,

including staff education and training, as well as assessment of patient suitability for satellite

dialysis. The Home dialysis unit also provides peritoneal dialysis training for patients in the

Yarmouth Renal Program, and works collaboratively with the PEI renal program with PEI PD

patients.

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Distribution of Home and Satellite Dialysis Patients

Distribution of Home and Satellite Dialysis Patients Number

Pts on Satellite HD at year end 112

Pts on Home hemodialysis at year end 17

Pts on PD at year end 59

Total number of patients followed by Home Dialysis

unit (HHD, PD, and Satellite) at year end

188

Number of Home Visits

Home Visits Number

Home Visits (HHD patients) 73

Home Visits (PD patients) 2

Total number of home visits (PD and HHD) 75

Number of Teaching Days

Teaching Days Number

Total Number of Teaching Days (HHD) 199

Total Number of Teaching Days (PD) 285

Total number of Teaching Days (PD and

HHD)

484

Number of Clinic Visits

Clinic Visits Number

Scheduled Clinic Visits (HHD and satellite

HD)

275

Unscheduled Clinic Visits (HHD and satellite

HD)

23

Scheduled Clinic Visits (PD) 229

Unscheduled Clinic Visits (PD) 99

Total Number of Clinic Visits (scheduled

and unscheduled; PD and HD)

626

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Peritonitis Rates for the Home Dialysis Unit

Infection rates are reported form 01/01/2011 to 12/31/2011. Targets are calculated as total patient

months on PD per episodes of peritonitis or exit site infections.

Program Target Actual Infection Rate

Peritonitis 1:36* 1:29.4

Exit Site Infection 1:48 1: 188.2

*International Society for Peritoneal Dialysis (ISPD) guidelines identify that minimum targets

should be 1:18. Despite not meeting Peritonitis program target rates, the renal program is

exceeding international standards.

In-Centre Hemodialysis Unit

Unit Capacity

The in-Centre renal hemodialysis unit (RDU) is the largest hemodialysis unit in Nova Scotia.

The unit provides treatment for chronic hemodialysis patients, and also provides support for the

satellite, home dialysis, and PD patients requiring re-assessment or short-term in-centre

treatments. As CDHA is a quaternary institution and transplant centre for Atlantic Canada, the

in-centre unit also provides hemodialysis treatments to chronic hemodialysis patients from other

programs in NS or other Atlantic Canada programs who require the specialized services offered

at CDHA. The scope of responsibility of the in-centre hemodialysis unit requires flexibility to

accommodate these needs, and as such strives to operate at 85% capacity.

The unit operated at over 100% capacity of approved hemodialysis stations for each month of the

2011 fiscal year. In 2011, the provincial government announced funding for the planning of an

expansion of six hemodialysis stations. This expansion will increase the number of approved

stations from 34 to 40, and subsequently increase the daily capacity from 102 treatments to 120

treatments.

Capacity limits are calculated by multiplying the number of approved of stations (34) by 3 shifts

per day to determine the daily capacity. As the unit operates two different schedules (Monday,

Wednesday, Friday, OR Tuesday, Thursday, Saturday), the maximum unit capacity is achieved

by multiplying the daily capacity by 2. Actual capacity= (34 X 3) X2. Actual capacity is 204

spaces.

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Capacity Overview by Monthly Averages

Month Occupancy % Capacity

April 2011 216 106%

May 217.8 107%

June 221.25 108%

July 229.75 112.6%

August 232.6 114%

September 229.25 112.4%

October 225 110%

November 223.6 109.6%

December 219 107%

January 2012 219.4 107.5%

February 219.25 107%

March 221.25 108%

Yearly Mean 222.8 109%

0

50

100

150

200

250

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

b…

Octo

be

r

No

vem

ber

De

cem

ber

Janu

ary

Febru

ary

March

21

6

21

7.8

22

1.2

5

22

9.7

5

23

2.6

22

9.2

5

22

5

22

3.6

21

9

21

9.4

21

9.2

5

22

1.2

5

Actual Capacity

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Acute Off-Unit Hemodialysis Treatment Support

The in-centre hemodialysis unit provides acute hemodialysis support to all ICU and IMCU units

within CDHA. The need for each acute hemodialysis treatment is individually assessed by a

nephrologist on the consult service, and each treatment is prescribed individually. These

treatments are provided at the patient‟s inpatient bedside for patients who require ICU or IMCU

care and monitoring. These hemodialysis treatments are staffed at a ratio of 1:1 (one

hemodialysis RN to one patient).

Treatment

Type/

Location

1st

Acute

HD

Subsequent

Acute HD

1st

SLED

Subsequent

SLED

CRRT* Toxic

Ingestion

UF

Only Total

3A 32 78 17 38 51 1 0 217

5.1 9 23 11 27 1 0 0 71

5.2 20 43 7 19 56 0 0 145

6.4 50 94 4 2 0 0 0 150

IMCU‟s 38 194 10 39 2 0 0 283

ER 18 2 2 0 0 0 0 22

Not

Identified

6 11 0 5 0 0 0 22

Total 173 445 51 130 110 1 0 910

* CRRT treatments are performed by the ICU bedside RN, not by a hemodialysis unit RN

0

50

100

150

200

250

1st Acute HD

Subsequent Acute HD

1st SLED

Subsequent SLED

CRRT

Toxic Ingestion

UF Only

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Fall-Back Support

The in-centre hemodialysis unit provides support to the satellite and home dialysis programs, and

dialyzes patients from these programs when needed. This support is either by providing

hemodialysis in-centre, or by in-centre dialyzing fallback patients in ICU‟s or IMCU‟s when

required. The in-centre unit also provides hemodialysis treatments to dialysis patients from the

Cape Breton Renal Program, the Yarmouth Renal program, and the renal programs from across

the Maritimes when patients from these programs come to CDHA for specialized treatments or

transplants.

Fallback

Location

Home

HD

PD Satellite

HD

DGH Yarmouth Cape

Breton

PEI Not NS

or PEI

Total

In-Centre

RDU

136 202 167 72 14 56 51 77 775

ICU 1 8 13 3 0 38 20 22 105

IMCU 8 1 8 5 1 3 11 8 45

ER 1 0 0 0 0 0 0 1 2

Total 146 211 188 80 15 97 82 108 927

Bacteremia Rates in Hemodialysis

Target Infection Rate for Tunneled Catheters: Less than 1.2 Infections per 1000 Catheter days

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

Rat

e /

10

00

Lin

e d

ays

2011 RDU Tunneled Line Infection Rates

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Target Infection rate for AVF’s: 0% Infections

Target Infection rate for Non-Tunneled Catheters: Less than 2.2 Infections per 1000 Catheter days

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5


Rat

e /

10

00

no

n t

un

ne

l lin

e d

ays

RDU 2011 Non tunneled Line Infection Rates

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0


Rat

e /

10

00

fis

tula

day

s

RDU 2011 Fistula Infection Rates

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Balanced Scorecard

The balanced scorecard is a quality communication tool that was developed by Capital District

Health Authority (CDHA) to be a template for quality work and reporting. The framework for

the scorecard is grounded in the five milestones: Person-Centered Health Care; Citizen

Engagement; Transformational Leadership; Innovative Health and Learning; and, Sustainability.

The balanced scorecard meets milestone and accreditation requirements, and also allows for a

showcase of unique quality initiatives. The balanced scorecard also serves as a reporting

template for bi-annual reports to the departmental quality and patient safety council.

**The balanced scorecard was showcased at the 2012 CDHA Quality Week Poster Fair.

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Accreditation 2013

The Renal Program Accreditation team evolved into the renal program quality and patient safety team

(Q&PS) in September of 2011. While accreditation remains a component of the group, the group also

focuses on ongoing quality and patient initiatives. This transition shifts accreditation requirements from a

cyclical nature to an ongoing philosophy and practice.

The most significant change for the 2013 Accreditation process is a change from Medicine Services to

Ambulatory Care Services. The rationale for this change is that the program felt the ambulatory care

standards were more appropriate for the program.

A new Required Organizational Practice (ROP) for 2011 is the Home Safety Risk Assessment.

The Renal program has been working with associated stakeholders to develop an efficient and

thorough process that meets the needs of patient, the program, and also the ROP tests for

compliance.

As of May 2012, the team has also begun reviewing ROPs as well as Standards of Practice, to

ensure that any identified deficiencies can be addressed in a timely, thoughtful manner.

Research

The Renal program is committed to improving the quality of renal care and is actively involved

in the research community. Following are studies that were commenced, on-going, or completed

in 2011.

Name of Study Study Lead Hypothesis # of

patients

enrolled

end

date

independent

or industry-

sponsored CanPreddict and

BIA: Collecting

data through

patient interviews

and blood tests

Dr. Steven

Soroka

To determine if there is a

biomarker profile which

predicts risk for

progression of CKD,

atherosclerotic events, or

heart failure in patients

referred to nephrologists.

96 from

Outpatient

nephrology

clinic.

2014

Grant Funded

ACE: The use of

the ACE inhibitor

Ramipril versus

Placebo in the

kidney transplant

pts.

Dr. Bryce

Kiberd

To determine if an ACE

inhibitor will decrease

protienuria and increase

the life of the transplant.

Kidney Transplant Clinic

7 2014 grant funded

P a g e | 23


patients

enrolled

end

date

independent

or industry-

sponsored PKD 251 Dr. Soroka To determine if the use of

Tolvaptan in the Adult

Dominant Polycystic

Kidney Disease patient

will decrease or inhibit cyst

growth on the kidneys.

Double blind study

6 Outpatient

clinic

2012 industry

funding

PKD 271 Dr. Soroka To determine if the use of

Tolvaptan in the Adult

Dominant Polycystic

Kidney Disease patient

will decrease or inhibit cyst

growth on the kidneys.

Open label study.

4 Outpatient

clinic.

Currently

enrolling.

2015 industry

funding

An Evaluation of

the

Pharmacokinetics

and

Pharmacodynami

cs of Oral

Dabigatran

Etexilate in

Hemodialysis

Patients

Drs. Jo-Anne

Wilson, Steven

Soroka, Kerry

Goralski,

David

Anderson,

Lekha Sleno

and Ms. Paula

Mossop

Hemodialysis patients

require a modified

dabigatran-dosing regimen

compared to individuals

with normal renal function

because of altered

pharmacokinetic and

pharmacodynamic

parameters

10 Fall

of

2012

Independent

Paradigm Dr. Soroka To demonstrate the

effectiveness of Cinacalcet

compared to traditional

Vitamin D in controlling

PTH level. Open label

study.

enrolled 6

Dialysis

Unit.

2012 industry

funding

Evolve Dr. Soroka To determine the

effectiveness of Cinacalcet

compared to placebo on the

time to death and non fatal

cardiovascular events,

unstable angina, heart

failure or a peripheral

vascular event. Double

blind study.

enrolled 6

Dialysis

unit.

2012 industry

funding

Identifying

Sources of

Decisional

Conflict in

Patients

Choosing A CKD

Treatment

Option.

David Landry,

NP

Does the Sure Tool and 16

item decisional conflict

questionnaire help to

identify concerns/barriers

to making decisions related

to the most appropriate

renal replacement therapy

in individual situations?

40 from

Outpatient

Nephrology

clinic.

Dec

2012

Independent

P a g e | 24


patients

enrolled

end

date

independent

or industry-

sponsored

Oral Sodium

Thiosulfate as

Maintenance

Therapy for

Calcific Uremic

Arteriolopathy

**This research

was showcased at

the 2012 CDHA

Quality Week

Poster Fair.

Dr. Al Bugami,

Dr. Wilson, Dr.

Clarke and

Dr.Soroka

To study the use oral STS,

costs 45 CAD per month

per patient (dose of 600 mg

thrice daily), as

maintenance therapy for

CUA, with the hypothesis

that

it will provide stabilization,

or even further regression

of the lesions at a

significantly reduced cost.

4 2011 Independent

CFDI: Canadian

Fabry Disease

Initiative

Dr. M. West Study of the clinical

outcomes of enzyme

replacement therapy in

Fabry disease

360 Sept

30,

2012

Shire HGT,

Genzyme,

provincial

govts of

Canada

BH4 Dr. M. West Study of tetrahydrobiopterin

(BH4) blood levels to

confirm earlier observation

that levels are low in Fabry

disease.

40+ open Investigator

sponsored

CFSSI:Canadian

Fabry Stroke

Screening

Initiative

Dr. M. West Study of idiopathic stroke

pts 18-55 yrs in Canada with

DNA analysis to screen for

Fabry disease as a cause.

6+ 2014 Investigator

sponsored

with a grant

from Shire

HGT

Fabry Alopecia

Study

Dr. M. West Study of male pattern

baldness in Fabry men to

determine if hair loss pattern

is less severe conpared with

age matched controls.

20 open Investigator

sponsored

FOS:

Fabry Outcome

Survey

Dr. M. West Registry study collecting

clinical data on Fabry

patients.

72+ open Shire HGT

Fabry Registry Dr. M. West Registry study collecting

clinical data on Fabry pts.

76+ open Genzyme

P a g e | 25


patients

enrolled

end

date

independent

or industry-

sponsored

Gene Transfer

Therapy in Fabry

Disease

Dr. M. West A pilot gene therapy clinical

study directed towards

amelioration of Fabry disease

in men using Lentivirus-

transduced, autologous

CD34+ stem cells will

demonstrate safety and

feasibility.

0 2017 CIHR

sponsored

REP-081 Dr. M. West A phase III clinical trial to

determine the safety of a new

form of agalsidase-alfa

enzyme replacement therapy

in Fabry disease.

20 open Shire HGT

REP-082 Dr. M. West A phase III pharmaco-

dynamic pharmacokinetic

study of agalsidase-alfa

enzyme replacement therapy

in Fabry disease.

8 2013 Shire HGT

REP-001A Dr. M. West A prospective phase III trial

of increased dose of

agalsidase-alfa enzyme

replacement therapy in Fabry

disease.

5 2012 Shire HGT

IGNITE

(Orphan

Diseases:

Identifying Genes

and Novel

Therapeutics to

Enhance

Treatment)

Dr. M. West A sub-study in the Ethical,

Economic, Environmental,

Legal and Social Aspects of

Genomics (GE3LS)

component, which examines

the attitudes to genetic

testing of adults with

hypertrophic cardiomyopathy

being screened for Fabry

disease.

0 2015 Genome-

Canada

P a g e | 26

Initiatives

Evaluation of Frequency of Ferritin Blood work

Description:

There were contradictory routine physician orders for timing and frequency of Ferritin blood

work. Some orders were for every two months, and some orders were for every three months.

The Anemia Management Quality Team (AMQT) identified this discrepancy, reviewed current

literature, and benchmarked timing and frequency of Ferritin blood work across Canada.

Rationale:

The AMQT could not identify any advantage to a frequency of two months for drawing Ferritin,

and decided to draw all Ferritin blood work at an interval of three months.

Implications:

This change affects approximately 420 dialysis patients (PD and HD), and will reduce yearly

Ferritin tests from six to four per patient per year. This results in a reduction of approximately

840 tests per year. The individual lab cost per Ferritin test in CDHA is $19.23. Annual savings

are estimated to be $16000 (840 tests X $19.23/test). This initiative has subsequently led to a

thorough investigation of the utility of Ferritin as a tool for guiding anemia management theory.

Nephrologists and NPs were surveyed, and results will be presented to the Renal Executive.

Cookies and Linens and associated savings

Description:

The in-centre hemodialysis unit traditionally placed clean sheets on top of clean chairs, and

changed them between patients. Also, the unit traditionally kept individually cookies and juice

for treatment of hypoglycemia. Infectious Control (IC) was consulted to see if there were any

concerns with discontinuing the use of sheets on clean chairs. No concerns were identified by IC.

Rationale:

These cookies and juice evolved into comfort measures for patients, and were not meeting their

originally intended purpose. Patients are encouraged to bring their own snacks while on dialysis.

Individual juice boxes and individual cookie packages were discontinued by the program, as well

as sheets on chairs.

Implications:

Monthly savings from linens are approximately $2000, and for the juice and cookies, $300.

Annual savings for both of these changes result in cost savings of approximately $27 600.

P a g e | 27

Culturing with Peritonitis

Description:

The lab requested that the Renal Program review culturing practices of gram stain tests in cases

of peritonitis. The PD Quality Team subsequently reviewed all culturing practices related to

cases of peritonitis. Current culturing practices included PD effluent for culture and sensitivity

(C+S), gram stain, cell count. These tests were repeated every 48 hours until negative, and then

weekly. Cost related to these tests according to CDHA lab cost guide are: $14.59 aerobic and

anaerobic culture; $5.97 cell count; $4.20 Gram Stain. A typical case of Peritonitis would result

in culture, cell count, and gram stain being sent on average five to eight times at a cost of

approximately $120 to $200. In 2011, there were 32 cases of confirmed peritonitis. The team

reviewed 2010 ISPD guidelines, as well as benchmarked against other PD programs in Canada.

The team also collected baseline data including cases of peritonitis, and catheter loss related to

peritonitis.

Intervention:

The PD Quality Team implemented new culturing practices which reduces the number of

cultures sent with suspected cases of peritonitis from upwards of eight down to two. Cases of

peritonitis are being tracked, as well as corresponding outcomes. The intervention will be

evaluated at 6 months, as well as at 12 months.

Implications:

There are two significant implications. Firstly, PD patients will have a lessened burden with

drawing less specimens and transporting them to local laboratories. Secondly, a decrease in

cultures sent results in decreased lab costs. Each case of peritonitis could potentially cost $24.76

compared to $120 to $200. With 2011 Peritonitis rates, this intervention will potentially reduce

yearly lab expenses by $3000-$5500. Other cost reductions that are anticipated relate to a

decrease in use of supplies as well as time saved by PD patients collecting fewer specimens, and

fewer trips to labs to deliver specimens.

Benchmarking staffing ratios

Description:

To evaluate the effective distribution of staffing resources, a cross-country benchmarking survey

was distributed to in-centre hemodialysis units in Canada. Of 25 surveys distributed, there were

12 responses. The survey responses were compared to CDHA in-centre staffing ratios.

Intervention:

There were no changes identified as a result of this survey.

P a g e | 28

Implications:

CDHA in-centre hemodialysis unit is using staffing ratios that are consistent across Canada.

Also, the role of the LPN seems to be further developed at CDHA, compared to some other

programs.

Self-Care In-centre Hemodialysis

Description:

In September 2011, the in-centre hemodialysis unit began offering self-care as a treatment option for

patients dialyzing in-centre. The goals of self-care include: to increase self-management by patients;

empower patients to become active members of their health care team; and to use self-care as a bridging

opportunity to develop confidence and capacity for patients interested in home hemodialysis, but reluctant

in their ability or capacity to perform the treatments on their own. At the time of the report four patients

were performing their own treatments in-centre. The in-centre target is to have nine patients doing self-

care hemodialysis by the end of the 2012 calendar year.

Intervention:

The in-centre unit and home dialysis unit worked collaboratively to develop and adapt training and

education tools for self-care. The first two self-care patients also provided valuable insight and input these

education, training, and communication tools.

Implications:

There are currently four hemodialysis patients trained to perform their own treatments in-centre. All four

patients report very positive benefits associated with performing their own treatments, including more

confidence with interactions between nephrologists and nurse practitioners, and increased satisfaction

while on hemodialysis. There have been no patients choosing to bridge to home dialysis as of yet, but one

of the self-care patients has housing barriers that once resolved, will likely transfer to home hemodialysis.

**This initiative will be showcased at the 2012 CDHA Quality Week Poster Fair.

Pt’s Home Aranesp being used In-Centre

Description:

Many patients are started on Aranesp while they are in the Renal Clinic. When these patients start

hemodialysis in-centre, they bring their own supply of Aranesp to be used up before using the unit‟s ward

stock supply. There was no process for communicating that there was a „patient‟s own supply‟ to be used,

and often substantial amounts of Aranesp were expiring in fridges in-centre and had to be discarded.

Intervention:

A process was developed with the program pharmacist, renal educators, and charge nurses in-centre to

use up a patient‟s own supply before transitioning to the ward stock. This process was communicated by

the renal educators to the in-centre staff, and a laminated poster was developed and placed near the

medication fridges.

P a g e | 29

Implications:

Dr. Wilson is tracking cost-avoidance by seeing all new patients who start hemodialysis, and recording

the number of syringes as well as the dose of medications. A cost-avoidance report will likely be ready

for the 2012 annual report.

CVC Line Study

Description:

A manufacturer was promoting a new CVC that they stated would decrease alteplase (TPA) usage. This

CVC was more expensive (CAD $410) than our standard CVC (CAD $150). A quality evaluation was

performed to test if this new catheter would decrease TPA usage in significant enough amounts to warrant

a change from our standard CVC.

Intervention:

A quality evaluation was performed to test if this new catheter would decrease TPA usage in significant

enough amounts to warrant a change from our standard CVC. The primary outcome measured was the

cost of TPA between the two catheters.

Implications:

There was no significant decrease in TPA usage with the new CVC. The program continues to use the

standard CVC.

**This initiative was showcased at the 2012 CDHA Quality Week Poster Fair.

Evening Social Work Coverage In-Centre Hemodialysis

Description:

Beginning in September 2011, social work services have been available to evening hemodialysis patients

on both schedules. For the period September 2011 through March 2012, with 3 FTE's covering the

Nephrology service, a social worker was available until 6:30 pm three weeknights per week. Since April

2012, with 2 FTE's, it is now available two nights per week. The schedule alternates days of the week to

enable each social worker to see their assigned patients, once every two weeks.

Intervention:

Social worker meets with patients/family members on evening shift (typically a Tues, Wed or Thurs),

providing interventions, as appropriate. Interventions include one to one emotional support, supportive

and/or resource counseling, education, consultation and collaboration with team.

Implications:

Increased access to social work services for evening patients/family members, resulting in increased

patient-centered care and increased continuity of care.

P a g e | 30

Evening Nurse Practitioner Coverage In-Centre Hemodialysis

Description:

The trial of NP presence on the in-centre hemodialysis evening shifts for helping to improve

continuity of patient/family care was one of the recommendations that came out of previous NP

Nephrology role reviews, and which included stakeholder feedback from in-centre evening shift

patients, family members, and interdisciplinary health care team members.

Intervention:

Patients are assessed by an NP on the two evening shifts (e.g. Tuesday & Wednesday evenings)

each week. NP focus is on the comprehensive assessment of, and collaborative care planning

with patients/family members who are new to hemodialysis and the Dickson unit.

Implications:

A recent survey of the majority of in-centre hemodialysis Registered Nurses and Licensed

Practical Nurses indicated overwhelming approval of the NP role on the evening shifts with

regards to consistency and comprehensiveness of health care provision and advanced nursing

support. A Renal Program Patient Flow Mapping Project is also underway. It includes an

independent evaluation by Joseph Beck, Management Engineer for Capital Health Performance

Excellence Program of the interdisciplinary care providers and patient/family's perceptions of

care provided/received when transitioning into the in-centre hemodialysis unit. His report is still

pending.

Venofer to Infed and associated savings

Description:

The use of medications was examined as a possible area of cost-saving to mitigate the deficit of the

program budget. CDHA as an organization identifies Iron Dextran (Infed) as the first choice when

prescribing and administering IV Iron. There was a perception that some patients were being started on

Iron Sucrose (Venofer) as first line treatment rather than Iron Dextran.

Intervention:

All patients who were using Venofer in-centre were identified, and were screened for documented

allergies to Infed. If there was no documentation that a patient had an allergy to Infed, or had never

received a test dose of Infed, the patient was identified, and trialed on a test dose of Infed. If no adverse

reactions occurred, the patient was switched from Venofer to Infed.

Implications:

Usage of Infed increased, while usage of Venofer decreased. Overall IV iron usage increased in the

program, while costs for IV Irons (Iron Dextran and Iron Sucrose) decreased. In the Dickson Centre, there

was a $5000 saving on overall Iron costs from the previous year, and in the DGH in-centre, there was a

$1000 overall savings from the previous year.

P a g e | 31

IV CalcijexOral One alpha

Description:

The use of medications was examined as a possible area of cost-saving to mitigate the deficit of the

program budget. The use of IV Calcijex in-centre was identified as a medication to review. Traditionally,

patients who were prescribed IV Calcijex had adherence issues, and were not consistently taking the oral

form independently.

Intervention:

The program switched all patients who were on IV Calcijex to the oral form, and were given the

medication while on dialysis.

Implications:

Monthly costs of Calcijex decreased from $1100/month to $200-$400/month, with yearly savings of

$8000-$9000.

Initiative Associated Savings

Ferritin 16 000

Culturing with PD 3000-5500

Cookies and Linens 27 600

Pt‟s own Aranesp in-centre N/A*

Benchmarking staffing ratio levels N/A

Self-Care In-Centre N/A

CVC Line Study N/A**

Evening NP and MSW N/A

IV VenoferIron Dextran 6000

CalcijexOne Alpha 8000-9000

Total 52 600-56 100

*This initiative would have no direct impact on the renal program cost savings, as Aranesp is

paid for by the provincial government. This initiative, however, demonstrates that the Renal

Program is a conscientious steward of public funds and resources.

** Despite not saving any resources, this quality initiative demonstrates responsible resource

allocation through a cost-benefit process.

P a g e | 32

Quality Care Teams

Renal Program Quality and Patient Safety

Description of Team:

The Renal Program Quality and Safety Team (Q&PS) evolved from the Accreditation team.

While still maintaining accreditation as a component of its mandate, the team also has a mandate

of monitoring and improving quality and patient safety in the renal program. Membership is

inclusive of all program areas and roles, and the team meets monthly.

Highlights:

Successes in the group include the development of the renal program balanced scorecard, and the

implementation of patient experience surveys to guide plan-do-study-act (PDSA) cycles of

improvement. Also, the team is fortunate to have three family members of patients that are part

of the team, and provide a valuable perspective.

Future Initiatives:

The team is beginning to prepare for the 2013 Accreditation survey, as well as conducting

ongoing patient experience surveys to stimulate PDSA cycles of improvement.

Areas for Improvement:

The Q&PS team is working to increase awareness of quality and patient safety initiatives in the

program, and is hoping that the balanced scorecard will help to increase awareness.

Respectfully Submitted by Matt Phillips

Anemia Management Quality Team (AMQT)


This team is comprised of membership from medicine, nursing and pharmacy with

representatives from Nephrology Clinic, Home Unit, In-Centre RDU and DGH Hemodialysis

and the Satellite Dialysis Units. The purpose of this team is to make evidence and practice based

recommendations regarding anemia management and to evaluate anemia targets in all areas of

the CDHA renal program.

Highlights:

Implementation of changes to the timing and frequency of measuring iron studies were

made based on current clinical practice guidelines as well as data collected from other

Canadian renal programs.

Quarterly anemia reports have been tailored to provide clinicians with the following

information:

P a g e | 33

o Site specific (e.g., Nephrology Clinic, Home Unit, In-Centre VG and DGH

Hemodialysis and Community Dialysis Units) attainment of anemia targets.

o Number of hyporesponsive patients (Defined as: Aranesp dosage ≥ 300

mcg/month and Tsat > 20% , Ferritin > 200 (HD) or > 100 (PD) and Hbg < 100

g/L).

o Number of patients on Aranesp medication with irons studies less than desired

anemia targets.

A quality board was developed to disseminate key information related to anemia

management within the CDHA renal program.

A policy regarding predialysis patients bringing in their home Aranesp medication to be

used in-centre when they start dialysis was developed. Cost-avoidance will be determined

with this initiative.

Future Initiatives:

To update all areas of anemia management in the CDHA renal program with the upcoming

revised Kidney Disease Improving Global Outcomes (KDIGO) anemia guidelines and Canadian

Society of Nephrology (CSN) commentary on the KDIGO anemia guidelines.

Respectfully Submitted by Dr. Jo-Ann Wilson

Cultural Diversity and Inclusion Committee


A Nova Scotia Renal Program Cultural Diversity project grant was obtained in March 2011 for

the Project, “The Mosaic of Nephrology Care at CDHA: On the Journey toward Cultural

Competence”. The Renal Cultural Diversity and Inclusion committee consists of representatives

from nursing, social work and the renal leadership team.

Highlights:

A foundational Education Day on “Cultural Competence and Inclusion” was held on January 17, 2012

with a presentation provided by Mohamed Yaffa, CDHA Diversity and Inclusion Coordinator. This

workshop concluded with group sessions to identify gaps in care of the culturally diverse individuals in

the Renal Program as well as priority areas for improving cultural competence.

As part of this initial project, patients were surveyed by Social Work committee members on

their perceptions regarding the Renal Program‟s areas of strength and areas for improvement. A

significant number of surveys were completed and identified recommendations related to quality

of care, quality of relationships and quality of environment/safety issues. All survey responses,

including a summary of results, were submitted to the Nephrology Quality Leader.

Future Initiatives:

Identified next steps (as based on patient & family surveys and education day evaluations) to

help us to create and maintain a healthy, respectful, and culturally competent workplace and

services include:

P a g e | 34

Visible and inclusive recognition of the diversity of Renal Program patients, families,

staff, etc.

Education session presentation by First Nations representative on the prevalent health

beliefs, value systems, and needs of this patient population

Ongoing consultation and education from the Capital Health Diversity and Inclusion

Coordinator and/or Team (s), as appropriate.

Respectfully Submitted by: Sohani Welcher, NP

Michelle Jensen, RSW

Kidney Patient Advocacy Committee (KPAC 3)


KPAC3 is a group of kidney patients and family members which was formed in 2010. Initially, the group

came together as an ad hoc committee formed with the intention of petitioning the government for

funding for much needed improvements to our dialysis unit. As a result of that task, we became a

permanent group representing dialysis patients and their families. We meet monthly with dialysis

administration and staff with the goal of presenting ongoing patient issues, in an effort to find the best

possible solutions.

Highlights:

In the past year we have dealt with many physical issues on the unit such as improvements in our public

washroom, initiating the placement of a new wheelchair corral in the Dickson, and making our waiting

room a bit more welcoming with some furniture and decorating improvements. We have also continued to

promote public awareness of dialysis with a variety of letters to the editor (Chronicle Herald) throughout

the year and we were able to do a poster presentation at the annual Social Work conference in September

2011. As well, some of our members have been invited to participate in other hospital committees

including Accreditation and Quality and Patient Safety.

Future Initiatives:

Our primary focus continues to be patient advocacy by acting as liaison between patients and staff. With

the constant growth and turnover in the dialysis population, we need to keep people informed of our

goals. To that end, we are now working on an updated letter to circulate to all of the patients in our units.


Going forward we need to obtain representation from all of the dialysis shifts so that the committee is able

to continue in the most effective way possible.

Respectfully Submitted by Patty Shea

P a g e | 35

Mineral Metabolism


The bone and mineral metabolism group was started 2 years ago and is made up of interested members of

the interdisciplinary team. The focus of the mineral bone disorder group continues to be on staff and

patient education.

Highlights:

Some of the activities undertaken include:

Patient Survey: Finding out what people already know, what they would like to know, and how

they like to receive information.

Patient Education: Sessions in waiting room, the patient report card and a display at the health

fair.

Staff Survey: A survey of staff education needs has been completed.

Staff education: Unit education blitzes have been done and “Did You Know” interesting facts

about mineral metabolism have been posted in the dialysis unit.

The Renal webpage is being used to post presentations and useful links to mineral metabolism

resources.

An evening education session for staff was held on April 12/12. This included an excellent presentation

from Dr. Dipchand and the group worked though some case studies and received a learning module on

Bone and Mineral disorders as well as a pocket guide and USB stick for quick access to Ukidney, an

online resource.

Future Initiatives:

The group plans to have another patient education opportunity, similar to the display at the health fair; but

closer to the dialysis unit so more people can participate.


One of our challenges is that our group has shrunk over the last year, so we welcome anyone with an

interest in doing some work around this important topic. Our meeting dates for the up-coming year are:

May 23/12 1300-1400, room 5132 (5th floor Dickson)

Sept 19/12 1300-1400, room 5132 (5th floor Dickson)

Nov 21/12 1300-1400, room 5132 (5th floor Dickson)

Respectfully Submitted by Marsha Wood, NP

PD Quality

Description of team:

PD quality team made of up Medical director of the PD program, the PD access nurse, home

dialysis RN‟s, educator, Health Service Manager, clinical leader, and quality leader. The

mandate of the team is monitor cases of infection, wait times, and PD targets in the program.

Also, the team continually reviews best practice guidelines, as well as benchmarks against other

PD programs.

P a g e | 36

Highlights:

Routine PD orders have been developed that are signed in the Renal Clinic before the patient

begins training. This has improved the transition from renal clinic to the home dialysis unit.

Also, in 2011 the PD Quality team has reviewed and changed the culturing practice in relation to

suspected peritonitis cases. The new practice will potentially reduce the laboratory-associated

costs of specimen-processing from approximately $120-$200/peritonitis to $25/peritonitis.

Future Initiatives:

The team is currently evaluating the utility and value of the 24 hour dialysate clearance for

patients using the cycler. The current practice is yielding results that are potentially skewed due

to collection techniques. The team is attempting to identify a process that will accurately and

effectively measure clearances.

Area for improvement:

The renal program is struggling to maintain the number of patients who choose PD as a renal

replacement choice. This is due to many factors, including PD patients being transplanted, as

well as the increase in uptake of home hemodialysis.

Respectfully Submitted by Cindy Everett

Practice and Safety


The Practice and Safety Team is comprised of the health service manager, clinical leader in-

centre, charge nurse in-centre, and front-line RN‟s and LPN‟s. The mandate of the team is to

meet monthly and identify areas for improvement in the in-centre dialysis unit, implement and

evaluate subsequent interventions to the identified areas of improvement, using PDSA cycles of

improvement.

Highlights:

The team has identified an opportunity for improvement in workload and flow of the unit by

changing the hours of the unit, and the hours of evening staff. The change results in evening staff

starting half an hour earlier, and being present for busier parts of the morning. The team is

tracking overtime after 11pm (the new closing time) to evaluate this change. Initial feedback has

been positive.

Future Initiatives:

The team is implementing a chart review tool for use by the patient care coordinator. The goal of

the implementation of this tool is to increase staff compliance with the role of the patient care

coordinator, and improve the documentation in the kardex. A pre-test has been distributed and

analyzed, and a post test will be distributed in approximately 6-8 months to evaluate the

implementation of the tool.

P a g e | 37


The team has a core group of members, and is open to all in-centre staff. The team has

acknowledged that recruiting new staff members is challenging. An area for improvement is to

expand the membership of the team.

Respectfully Submitted by Cynthia Stockman

Professional Practice


The Professional Practice Quality Team meets bi-monthly, and is made up of RN‟s, LPN‟s, a NP, both

clinical educators, both clinical leaders, and the nephrology quality leader. The focus of the group is on

professional practice issues and professional development.

Highlights:

The Professional Practice Quality Team has improved the yearly competency assessment forms. These

forms are mandatory for every front-line staff to complete on a yearly basis. During 2011, the team

transferred the forms to an electronic survey format which will facilitate tracking of who has completed

the forms, as well as significantly reduce the time and effort required to collate the over two hundred

forms yearly. Also, the team has been attempting to improve documentation practices within the program.

In an attempt to increase awareness in front-line staff of what is audited in documentation audits, each

front-line staff member was asked to complete two chart audits. The completion rate for this was almost

100%.

Future Initiatives:

The team will be evaluating the effectiveness of having front-line staff audit charts during the next chart

audit in the fall of 2012 (Q3). The team will also be reviewing feedback around the usability of the new

electronic forms for yearly competency forms.


A challenge for the Professional Practice Quality Team is that the renal program is spread out

over different geographical locations, including satellite units in rural NS, as well as the

Dartmouth in-centre dialysis unit. Also, despite having steady membership from the program

areas, the team struggles with attracting new members.

Vascular Access


The Vascular Access Quality care Team has

Established vascular access quality performance measurement indicators

Established what information needs to be collected, on what frequency, and how

reporting of identified quality indicators should be managed.

Identified, implemented, and monitored quality improvement initiatives through

quarterly and annual reporting

Engaged other renal program members in the collection and utilization of accurate,

evidence-based practice

P a g e | 38

A close relationship remains ongoing between the Division of Nephrology and our Interventional

Radiology colleagues as well as the dedicated surgeons involved with creating / revising AVF‟s.

Highlights:

Pre printed Order (PPO) developed for managing anticoagulation of low-risk patients going for

an IR procedure. This has been developed to increase patient safety and also to establish

consistency in practice. A component of this will be a patient education pamphlet.

Vascular Access Database transitioned into My Nephrology database in November 2011. This

database monitors patient‟s current access, lost access sites, radiology interventions, reasons why

the procedure was requested and the number of procedures pending and performed. Maintaining

the database, tracking and analyzing the data will enable us to measure quality indicators and

patient outcomes and identify areas for future quality improvement and research.

Future Initiatives:

The vascular access RN is working with a team to revise the Central venous catheter dysfunction

algorithm using evidenced-based research, as well as best-practice guidelines. This new

algorithm will be evaluated based on TPA usage, as well as monitoring line exchanges for poor

flows.

Respectfully submitted by Paula Mossop

Directions/Priorities for Future Planning

PATH/Conservative Management

Over the past few years, the Renal Program has developed a working relationship with the

Palliation and Therapeutic Harmonization (PATH) program. The renal program has referred

many patients and caregivers to the PATH clinic for comprehensive assessments to determine

cognitive status, functional levels and current health challenges. This process has resulted in

many patients and families choosing supportive and conservative care for their kidney disease.

The PATH process promotes thorough explorations of benefits and burdens associated with

various treatment modalities for kidney disease. This process helps identify levels of frailty and

how to best promote quality of life for patients and their families. In the near future, nephrology

nurse practitioner David Landry will begin a renal PATH clinic which will focus on completing

comprehensive geriatric assessments and offer a focus on conservative management/supportive

care for appropriate individuals. The renal PATH clinic is designed to provide care for people

with CKD that do not choose conventional dialysis treatments as their kidney disease progresses.

Home Therapies Initiatives

The Renal program has been consciously growing the capacity of the home dialysis program.

Home dialysis, both peritoneal and hemodialysis has similar or better outcomes than in-centre

P a g e | 39

hemodialysis, and is delivered at a lower cost. There are many barriers, though, to patients

choosing home dialysis as a treatment choice. The program is actively involved in the provincial

renal program home therapies steering committee. The provincial program has identified targets

of home therapy modality in 20% of all dialysis (PD and HHD) patients by the end of 2012, and

25% of all dialysis patients by the end of 2015.

Each area in the program is implementing initiatives to meet and surpass these targets. The Renal

Clinic has introduced a small group session, „Decision Support‟, that is offered after the

„Treatment Options‟ class. The goal of this small group session is to explore the components of

decision-making, and to guide the decision-making process using self-identified pros and cons of

each modality option for each individual facing the reality of choosing a dialysis therapy.

The Home Dialysis unit has made the commitment to start any patient on a home therapy directly

from renal clinic, and bypassing the traditional path of starting in-centre before moving to a

home therapy. The home dialysis unit is also developing a wait time indicator as a commitment

to providing training and support in a timely, transparent manner.

The in-centre unit has reserved stations for self-care hemodialysis. Patients who choose self-care

hemodialysis will be trained on their usual dialysis schedule, and will eventually perform some

or all of their treatments independently in the in-centre setting. This option of self-management

is ideal for patients who have an identified barrier to do home hemodialysis, but still have the

desire to self-manage. This modality choice can also serve as a bridging system for patients

wanting to do a home therapy, but reluctant to commit fully. Self-care in-centre will provide an

environment to develop self-confidence so that the skill may be seamlessly transferred to a home

setting.

Satellites to local health districts

The CDHA Home Dialysis program currently manages six satellite hemodialysis units including

Berwick, Liverpool, Truro, Pictou, Port Hawkesbury, and Springhill. The long-term goal of the

CDHA Renal program is for the satellites to evolve into a new model of care which will include

the transitioning of management and administrative responsibility to the health districts in which

the satellites are located. There are currently two Satellite dialysis units currently operating under

this new model: Antigonish and Sherbrooke. The next satellite unit planned for transition is the

Truro Satellite unit in November of 2012 with the opening a new Colchester hospital, which will

include a ten-station hemodialysis unit.

P a g e | 40

Addendum A: EPO Costs for In-Centre QEII and DGH Hemodialysis

This addendum has been added after the original publication of the 2011 Annual report that was posted

to the Renal Program CDHA public website on Sept 7, 2012. Note that this EPO represents only what is

used in DGH and Dickson (QEII) in-centre units only. EPO costs are not reported as CDHA Renal Program

costs because EPO is funded as part of the Department of Health and Wellness high cost drug program.

April 1 2010 to March 31, 2011

Darbepoetin and Epoetin Usage in QEII and DGH Hemodialysis 2010-2011

Site Generic Drug Cost

QEII Hemodialysis Darbepoetin $1,281,200.80

QEII Hemodialysis Epoetin $6,475.20

QEII Hemodialysis Total $1,287,676.00

DGH Hemodialysis Darbepoetin $240,637.20

DGH Hemodialysis Epoetin $6,771.60

DGH Hemodialysis Total $247,408.80

Grand Total for In-Centre Hemodialysis Units 2010 $ 1,535,084.80

April 1 2011 to March 31, 2012

Darbepoetin and Epoetin Usage in QEII and DGH Hemodialysis 2011-2012

Site Generic Drug Cost

QEII Hemodialysis Darbepoetin $1,309,528.40

QEII Hemodialysis Epoetin $6,498.00

QEII Hemodialysis Total $1,316,026.40

DGH Hemodialysis Darbepoetin $265,748.80

DGH Hemodialysis Epoetin $5,392.20

DGH Hemodialysis Total $271,141.00

Grand Total for In-Centre Hemodialysis Units 2011 $ 1,587,167.40

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