Celbrating Ten Years of an Established Pre-Dialysis Service in South-East Wales

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CELBRATING TEN YEARS OF AN ESTABLISHED PRE-DIALYSIS SERVICE

Thomas N, Aggett J, Pugh J, Goodland A, Prichard A

Nephrology and Transplant Directorate, University Hospital of Wales, Cardiff

BACKGROUND: In 2004 three new Pre-Dialysis Clinical Nurse Specialists (CNSs) were appointed to join the existing single CNS in post, resulting in a team of 3.8 wte Band 7s. Each CNS has a designated lead role and works with identified Nephrologists linked to specific nephrology clinics. Initial issues identified included a high number of late presenters and high incidence of central line use. Patient education was limited to that provided by the Nephrologists in clinic consultations. Pre-dialysis care was agreed to be overly fragmented between professions with anaemia, access and education all being provided separately. Initially each CNS had a caseload of 73 patients, including a small number of conservative management patients.

SERVICE DEVELOPMENT: All patients referred from 2004 had a home visit within a week by a CNS to provide education and to carry out a physical, psychological and social assessment. Existing patient information resources were revamped. New patient information materials were created including a laminated picture booklet, learning disability booklet, audio CD, Conservative Management (CM) pamphlets, and an Option Grid (available nationally). Weekly multi-disciplinary patient information mornings and a thrice yearly support group were established. Essential to this was the participation of be-frienders from the Welsh Kidney Patient Association who the CNS team develop and train alongside the Clinical Psychology Service. The CM programme was developed further with the appointment of a 5th CNS in 2007. The CNS team were key in the repatriation of all ESA prescribing back in-house, resulting in a significant cost saving to the Welsh Renal Clinical Network, and monitor all renal anaemia care for pre-dialysis/CM patients. A local IV iron outreach clinic has been set up; resulting in significant saved journey times for patients. We co-ordinate the Hepatitis B vaccination programme for pre-dialysis patients. We undertake an annual audit which is presented at the Trust Clinical Governance and we have also nationally published numerous articles or presented at conferences. We have facilitated and organised well-received local seminars on CKD and renal anaemia care aimed at Primary Care.

CURRENT STATUS: The total number of patients seen by a CNS for a pre-dialysis home visit since 2004 is 3,037. Additionally 642 patients/carers to date have attended one of the 5-week Support Group programmes. Patient information mornings have been extended to outreach hospitals and an evening Young Patient Group was piloted in 2014. The number of late presenters has significantly decreased and as a direct result of information presented from our audits a dialysis access team is now established with corresponding improvements in vascular access for the unit. Unfortunately the team has decreased from 5.8 wte to the current establishment of 3.6 wte, meaning each nurse now has a caseload of approximately 199 patients.

THE NEXT TEN YEARS: The CNS team need to take on the challenges of an increasingly elderly population, in giving them appropriate choices, support and developing the use of Advanced Care Planning documentation. The increased options for patients in the fields of transplantation and home therapies also offer challenges in ensuring all patients receive relevant and necessary information to make an informed choice. The team are undertaking an ongoing project on Shared Decision Making that has already led to the creation of the Option Grid with a local University. The team are keen to engage more with Primary Care and to develop nurse led clinics in outreach hospitals, currently issues of space are barriers to this. Increased use of technology offers opportunities to further develop educational materials for patients and allow for more flexible working.