st pancras community ckd service - london …€¦ · community ckd service • ckd pathway agreed...
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St Pancras Community CKD Service
Sheila Johnston
Lead Nurse CKD
Royal Free London NHS Foundation Trust
Case for Change
• Current model: Secondary
care and hospital centred
• Patients travel to us
• No strategy for prevention
• Treating disease reactively :
Expensive
Community CKD Service • CKD pathway agreed
with 3 locality GP CKD
leads
• Established referral
criteria
• EMIS records
( data sharing agreement)
• Service model agreed
• Embed community CKD
with local primary care
• Support GPs to manage
CKD
Virtual clinic
Secondary care
Community Nurse led
clinics
Community CKD Service • Primary Care
Partnership
• Virtual clinic
• Joint nurse led clinics
• Self management
• Shared decision
making
Referral Criteria
Urinary symptoms
Medical history
Medication
Examination e.g. BP,
oedema, palpable bladder
Urine dipstick for blood and
protein: ACR
Serum creatinine and eGFR, urea, sodium, potassium, albumin, calcium, phosphate, cholesterol, FBC, HbA1c
Historical creatinine results and eGFR
Result of renal ultrasound
Number of patients on CKD Practice Register
4400
4500
4600
4700
4800
4900
5000
5100
5200
5300
5400
As on 12/09/2014 As on 01/04/2014 As on 01/04/2013
4900
4920
4940
4960
4980
5000
5020
As on 12/09/2014 As on 01/04/2014 As on 01/04/2013
Number of patients with eGFR <60 (2 readings more than 7 days apart)
3400
3500
3600
3700
3800
3900
4000
4100
As on 12/09/2014 As on 01/04/2014 As on 01/04/2013
Number of patients with eGFR <60 (2 readings more than 7 days apart) on CKD register
0
200
400
600
800
1000
1200
1400
As on 12/09/2014 As on 01/04/2014 As on 01/04/2013
Number of patients with eGFR <60 (2 readings more than 7 days apart) not on CKD register
(uncoded)
0
5
10
15
20
25
30
35
40
45
50
As on 12/09/2014 As on 01/04/2014 As on 01/04/2013
Number of patients on CKD Register but no eGFR <60 (miscoding)
QOF outcomes
4000 4500 5000
As on12/09/2014
As on01/04/2014
As on01/04/2013
Those with BP in last 12 months
3000 3500 4000
As on12/09/2014
As on01/04/2014
As on01/04/2013
Those with BP < 140/85
0
500
1000
1500
2000
2500
3000
3500
4000
As on 12/09/2014 As on 01/04/2014 As on 01/04/2013
Those with ACR in last 12 months
QOF Outcomes
72% 73% 73% 73% 73% 73% 74% 74% 74% 74%
As on 12/09/2014
As on 01/04/2014
As on 01/04/2013
Proportion of patients with ACR > 30 on ACEi or ARB (287 patients out of 391)
Patient Outcomes
Measuring long term outcomes for patients seen in last 3 yrs
eGFR
Progression of CKD
BP management