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Outline

Renal Services in • Outline of renal services in Gibraltar Gibraltar • Challenges with a public health flavour Dr Simon Lines BSc MBChB FRCP PhD Consultant Nephrologist and General Physician October 2018

Aberdeen Royal Infirmary Royal Infirmary Margate Warrington Aberystwyth, Bronglais Hospital Edinburgh Western General Satellite Unit Medway Washington Satellite Dialysis Unit Accrington Elgin - Dr Gray's Hospital Melrose - Borders General Hospital Watford Hospital - Horace Robinson Dialysis Centre Airdrie - Monklands Hospital Exeter - Heavitree Haemodialysis Unit Merthyr Tydfil - Fresenius West Byfleet Dialysis Unit Aldeburgh Exeter Kidney Unit - Royal Devon & Exeter Hospital - The James Cook University Hospital Weston Super Mare - Ambleside Unit Alnwick Dialysis Unit Farnham Dialysis Unit Milford-on-Sea Whipps Cross Satellite Unit Antrim Area Hospital Forest Hill/ Milton Keynes - Milton Keynes Hospital Whitehaven Arbroath Fort William Mountainhall Treatment Centre Wick Ashford, Kent Forth Valley Royal Hospital New Cross Gate Satellite Dialysis Unit Wigan Ayrshire & Arran: University Hospital Ayr Frome Community Hospital Newcastle - The Hospitals NHS Foundation Trust Windsor Dialysis Unit UK Renal Units Ayrshire & Arran: University Hospital Crosshouse, Kilmarnock Glan Clwyd Hospital Newcastle RVI - Paediatric Unit Banff - Chalmers Hospital - Yorkhill Newham Satellite Unit Woolwich Satellite Unit (King's College Hospital) Bangor - Gwynedd Hospital Glasgow Renal and Transplant Unit Newport - B.Braun Avitum Worcester Barnet Dialysis Unit Glasgow Royal Newry - Daisy Hill Hospital Worthing Dialysis Unit Barnsley Glasgow Stobhill North Devon - Barnstaple Satellite Unit Basildon Gloucester North Ormesby Dialysis Centre Yarmouth - Gorleston Basingstoke Grimsby Northampton Yeovil Bassetlaw Dialysis Unit Guernsey Norwich Bath - Royal United Hospital Halifax Satellite Unit Children's Unit Belfast City Hospital Harrogate Nottingham Renal and Transplant Unit Belfast- Ulster Hospital Nottingham University Hospitals, Queens Medical Centre Dialysis Unit Bexhill Dialysis Unit Haverfordwest Nuneaton - George Eliot Hospital Birkenhead - Arrowe Park Hospital Hereford Dialysis Centre Omagh - Tyrone County Hospital - Cross High Wycombe - Wycombe Hospital Orkney - Balfour Hospital 86 Main renal units Birmingham - City Hospital Satellite Unit HinchingbrookeDialysis Unit Orsett Hospital Birmingham - King's Norton Honiton (East Devon Satellite Kidney Unit) Kidney Unit and Oxford Transplant Centre Birmingham - Huddersfield Satellite Unit Penzance Birmingham - Woodgate Hull Perth Birmingham Children's Hospital Ilkeston Community Hospital, Shipley Dialysis Unit Peterborough Birmingham Heartlands Inverclyde Peterhead Birmingham Queen Elizabeth Hospital Inverness - RaigmoreHospital Plymouth - Plymouth Dialysis Unit Blackburn Haemodialysis Unit Inverurie Pond Lane Renal Unit Blackpool (Clifton) Ipswich Renal Unit Satellite Unit Bodmin Dialysis Unit Isle of Wight - Queen Alexandra Hospital Bognor Regis - Springfield Renal Care Centre Kendal - Westmoreland General Hospital Preston - Royal Preston Hospital Bolton - Royal Bolton Hospital Kettering Princess Royal Hospital NHS Trust Borough Kidney Treatment Centre Kidderminster Dialysis Centre Queens Satellite Unit Boston King's Lynn Reading - Royal Berkshire Hospital Bournemouth Kingston Dialysis Unit Haemodialysis Satellite Unit Bracknell Kirkcaldy Rotherham Kirkcudbright Hospital Royal Alexandra Hospital, Paisley Bridlington - Beeston Satellite Unit Royal Derby Hospital Brighton - Sussex Kidney Unit Leeds - Paediatric Unit Royal 's Children's Hospital Bristol - South Bristol Leeds - Intermediate Unit (Wards R&S) Rugby - St Cross Hospital Bristol Bright Dialysis Unit Leeds - Seacroft Satellite Unit (Ward B) Runcorn Road Satellite Renal Unit Bristol Children's Hospital Leeds - St James's University Hospital Salford Royal NHS Foundation Trust Bristol Southmead - General Hospital Salisbury Bromley Satellite Unit (King's College Hospital) Leicester Renal Dialysis Unit Scarborough Buckland Satellite Unit Lichfield Victoria Hospital Scunthorpe 285 dialysis units Burnley - Burnley General Hospital Lincoln Severn Bury St Edmund's - West Suffolk Hospital Litchfield Dialysis Centre Camberwell - Guy's - Aintree University Hospitals NHS Foundation Trust Sheffield - Heeley Cambridge - Addenbrooke's Hospital Liverpool - Broadgreen Shetland - Gilbert Bain Hospital Cannock Liverpool - Royal Liverpool University Hospital Sidcup Satellite Dialysis Unit Canterbury Liverpool - Waterloo Skegness - LlantrisantB Braun Liverpool - Whiston Skipton Cardiff - North (Pentwyn) - B.Braun Avitum Liverpool Children's - Alder Hey District General Cardiff - University Hospital of Livingston - St Johns Hospital South Devon Satellite Kidney Unit Cardiff South Renal Unit B Braun Llandrindod Wells - Totton Carlisle - Cumberland Infirmary London - Barts and The London Hospital Southampton General Hospital - Paediatric Carmarthen, West Wales Hospital London - Camden Southend Hospital Castle Vale satellite renal unit London - Central Middlesex Hospital Brent Renal Centre Southport Dialysis Unit Chandlers Ford Dialysis Centre Fresenius Medical Care Ltd. London - Charing Cross Hospital St Alban's Chelmsford - Broomfield Hospital London - Ealing St Andrews Satellite Unit Chesterfield London - Evelina Children's Hospital St Bartholomews Satellite Unit Chorley London - Great Ormond Street St Helier's South West Thames Renal & Transplantation Unit Clatterbridge- Arrowe Park London - Guy's Hospital St Pancras - Royal Free & Middlesex Colchester Dialysis Unit London - Hayes Stafford Corby Renal Dialysis Unit London - Highgate Stevenage CosshamDialysis Unit London - King's College Hospital Stockton Dialysis Centre Countess of Chester Hospital NHS Foundation Trust London - North Middlesex Stoke - University Hospital of North Staffordshire Coventry - WalsgraveHospital London - Northwick Park Hospital Dialysis Centre Stoke Mandeville - Stoke Mandeville Hospital Crawley Dialysis Unit London - Peritoneal and Auchi Dialysis Centres: Hammersmith Hospital Stornoway Crewe - Leighton Hospital London - Royal Free Hospital Stranraer - The Galloway Hospital Cromer Haemodialysis Unit London - St Charles' and Hammersmith Dialysis Centre Stratford upon Avon Darent Valley Satellite Unit (King's College Hospital) London - St George's Hospital Royal Hospital Darlington Dialysis Centre London - St John & Elizabeth Swansea, Morriston Hospital Dearne Valley Dialysis Unit London - St Mary's Hospital Swindon - Great Western Hospital Derry/Londonderry - Altnagelvin Hospital London - West London Renal and Transplant Centre Sydenham Satellite Unit (King's College Hospital) Dewsbury Satellite Unit London - West Middlesex Hospital Dialysis Centre Hospital Loughborough Taunton Dialysis Centre Dorchester Luton The Elizabeth Ward Dialysis Unit, Mayday Hospital Dudley - Russells Hall Hospital Maidstone The Shrewsbury and Telford Hospitals NHS Trust Dulwich Satellite Unit (King's College Hospital) Manchester - Altrincham - Ninewells Manchester - Macclesfield General Hospital Truro - Royal Cornwall Hospital Dunfermline - Queen Margaret's Hospital Manchester - North Manchester General Hospital Tunbridge Wells Kidney Treatment Centre Durham Dialysis Centre Manchester - Prestwich Vale of Leven Easingwold Manchester Royal Infirmary Victoria Infirmary, Glasgow Eastbourne - Polegate Mansfield Dialysis Centre

Renal services in UK • Hub and spoke model Long way from UK! • MDT approach: – Colleagues , specialist nurses (transplant (donor & recipient), anaemia (EPO & iron), pre-dialysis education, vascular access, peritoneal dialysis ), histopathologists, transplant surgeons, vascular surgeons, psychologists, dieticians, social workers, interventional radiology • Comprehensive renal replacement programme – Haemodialysis, peritoneal dialysis, transplantation, Gibraltar has 1 renal unit conservative care, ITU-based renal replacement therapy

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Renal services in UK Gibraltar Haemodialysis • Hub and spoke model • MDT approach: • Capacity – Colleagues, specialist nurses (transplant (donor & • Infection control recipient), anaemia (EPO & iron), pre-dialysis education, vascular access, peritoneal dialysis ), • Logistics histopathologists, transplant surgeons , vascular surgeon s (visiting), psychologists , dietician s, social workers, interventional radiology • Comprehensive renal replacement programme – Haemodialysis, peritoneal dialysis, transplantation, conservative care , ITU-based renal replacement therapy

Haemodialysis in Gibraltar Capacity

Capacity Capacity

• Summer ‘17: 3 shifts (Mon, Weds, Fri), 3 staff nurses & 1 HCA • Now: 4 shifts across 6 days, ≈9 nurses & 1 HCA • 8 stations – Water treatment plant too small – 2 in isolation room…

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Planned unit expansion Infection control • Upgraded water plant • More stations • “Isolation” room has 2 beds in it • Isolation facilities • Hepatitis B • Hep B capability

What to do while works underway?

Infection control

• “Isolation” room has 2 beds in it • Hepatitis B – Historical poor rates of Hep B vaccination • Oct ‘17: 10/21 (45%) HbsAb +ve • Sept ‘18: 22/28 (79%), non-responders 6/28 (21%) – Proactive vaccination in the pre-dialysis setting – 5 Moroccan patients with frequent (unscheduled) trips abroad • MRSA – Introduced screening 6 monthly – Reduced catheter usage: 5/22 (23%) -> 4/28 (14.3%)

Infection control - Environment

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Infection control - Environment

Logistics Logistics

• Brexit… • No dialysis software – 9/10 staff reside in Spain • Transplantation – All consumables come across the border by road – Patients on transplant list in Hammersmith • Single water plant: • 12hr window from call -> De Wardener Ward, HH – Everything in duplicate • 3 months minimum in London, frequent trips thereafter • Single nephrologist: – Turnaround time for drug assays is weeks – Tissue typing samples sent by courier – No cover: Saturdays, leave • No on-site vascular surgery • No peritoneal dialysis or interventional radiology

Logistics

• Renal replacement therapy for AKI – No dialysis staff on call – Previously team from hospital in Malaga delivered CVVHF on ITU – Now developed in house expertise using citrate- based CVVHD • Very complicated • Infrequent, 8 pts since Jan’18, 0 pts since May’18 (skill fade)

Poster at GHA nursing conference October 2018

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Summary

Number of unique challenges to delivering renal services in Gibraltar, some challenges not so unique…

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