{"id":7777,"date":"2020-07-30T16:45:58","date_gmt":"2020-07-30T15:45:58","guid":{"rendered":"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/?page_id=7777"},"modified":"2024-02-22T09:38:23","modified_gmt":"2024-02-22T09:38:23","slug":"birmingham-haemodialysis","status":"publish","type":"page","link":"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/birmingham-haemodialysis\/","title":{"rendered":"Haemodialysis"},"content":{"rendered":"\n
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Learning from one renal unit\u2019s transformation in response to COVID-19<\/h2>\n\n\n\n
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Authors<\/h2>\n\n\n\n

Stephanie Stringer, Annette Dodds, Anne-Marie Phythian, Lynette Groombridge and Gabby Hadley <\/em><\/p>\n\n\n\n

Context<\/strong><\/h2>\n\n\n\n

In the period prior to the Covid-19 pandemic we were in the process of merging with another organization, this means that in addition to the substantial changes associated with managing covid-19 we were also managing a much larger HD service with historically different ways of working across sites. In many ways the necessity of a centralized and uniform service created by the demands of Covid-19 accelerated the integration of the two services and as a result we are now a far more unified service than previously. This is probably the greatest overall benefit to us but other, specific, beneficial changes are listed below <\/p>\n\n\n\n

Summary of beneficial changes<\/h2>\n\n\n\n
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    \n
  1. Rapid creation of in centre HD capacity for purposes of cohorting<\/li>\n\n\n\n
  2. New starters beginning HD at satellite units<\/li>\n\n\n\n
  3. Incremental HD starts for new patients<\/li>\n\n\n\n
  4. Management of staffing shortages: nurses who had previously worked in HD<\/li>\n\n\n\n
  5. Management of staffing shortages: medical students and sexual health nurses to work as HCAs and DSW<\/li>\n\n\n\n
  6. The use of technology to replace face to face activity in the satellite program<\/li>\n\n\n\n
  7. The rapid production of Standard Operating Procedures, training documents and patient communication <\/li>\n<\/ol>\n<\/div><\/div>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n
    \n\n\n\n

    Rapid creation of in centre HD capacity for purposes of cohorting<\/h3>\n\n\n\n

    This was something that we had been trying to do for some\ntime; it had previously proved very difficult to get patients out into the\nsatellite program from the hub units mainly because of a combination of patient\nreluctance to move to a less supervised environment and mainly capacity in the\nsatellite program. Covid-19 made both easier; patients felt that they would be\nmuch safer in the satellite program (at the very outset I walked round all the\npatients with the lead nurse and explained that soon the outpatient slots in\ncentre would become cohort shifts with potentially infected patients). Patients\nwere made aware that their move to a satellite unit would be a permanent one.\nWe did retain a small number of in centre patients who were not suitable for\ntransfer out (usually because they are medically too unstable or they require a\nbed for dialysis). We created satellite capacity in the following ways;<\/p>\n\n\n\n

      \n
    1. As soon\nas a patient from a satellite unit was admitted we used their slot (we would\nhave previously waited for 2 weeks before releasing their slot)<\/li>\n\n\n\n
    2. We\nopened up twilight slots at two NHS units and expanded slots at another private\nprovider unit<\/li>\n\n\n\n
    3. We\ninstituted a policy of HD reduction for shielding purposes to 2x weekly for\nsuitable patients. This created capacity though that was not the main aim of\nthe policy<\/li>\n\n\n\n
    4. Sadly\npatient deaths also created satellite capacity<\/li>\n<\/ol>\n\n\n\n

      We plan to maintain this by keeping very close oversight of\nthe in centre units, having clearer oversight of the satellite capacity and\ncontinuing to keep the extra slots open as required.<\/p>\n\n\n\n

      New starters beginning HD at satellite units<\/h3>\n\n\n\n

      Prior to Covid-19 new dialysis starters almost always had\ntheir initial dialysis in centre and then moved to a satellite unit following\nthis, the exception is the patients who were looked after by the Heartlands\ngroup who were able to start dialysis at one of their NHS satellite units.\nWhile there are advantages to beginning dialysis in centre (the presence of\nmedical supervision and access to nurses with specialised cannulation skills) a\nmajor disadvantage of starting patients in centre is that it can become very\ndifficult to move them out in a timely fashion which can result in the filling\nup of in centre capacity. We felt that it was important to unify this process\nand we did this in the following ways;<\/p>\n\n\n\n

        \n
      1. We discussed this with our private providers who\nwere keen that we develop a formal pathway for this<\/li>\n\n\n\n
      2. We developed an SOP which stated that unless\nthere is a specific indication to start in centre all patients will be assumed\nto be suitable for a satellite start<\/li>\n<\/ol>\n\n\n\n

        Incremental HD starts for new patients<\/h3>\n\n\n\n

        Prior to Covid-19 we had discussed the use of incremental\ndialysis starts for new patients but had not managed to roll this out. At the\noutset of Covid-19 we decided that we would immediately commence this and we\ndid so using the following process;<\/p>\n\n\n\n

          \n
        1. The CKD team were told that this was now how patients will be starting HD (unless there is a specific clinical request to start at thrice weekly)<\/li>\n\n\n\n
        2. Pre dialysis education (such as it was during the pandemic) was updated<\/li>\n\n\n\n
        3. The core HD coordination team ensured that patients who started HD after a hospital admission were assessed for their suitability for an incremental start by the Consultant discharging them<\/li>\n\n\n\n
        4. Patients starting in this way are all told that at some point a clinical decision will be made to increase their dialysis to thrice weekly<\/li>\n<\/ol>\n\n\n\n

          Centralised control of the HD program by a small team<\/h3>\n\n\n\n

          During covid-10 the changes to inpatient rotas meant that\nthe availability of the Consultant workforce to continue to provide medical\nsupervision for their satellite units was radically reduced. This left a very\nsmall core of Consultants and specialist nurses to run the entire program, the\nsatellite units were forced to manage with significantly less medical support\nthan usual and in almost all cases they did so. We ensured that the units all\nstill had access to urgent medical support, weekly troubleshooting calls and\nmonthly dialysis QAs (done remotely). We set up an email inbox for all HD queries\nso that they could be dealt with centrally. All of the monitoring of the twice\nweekly shielded patients was conducted by this group. This was a great deal of\nwork but the program ran safely and efficiently during this time. While this\nwas not a permanent change to our model of care the following aspects could\npersist;<\/p>\n\n\n\n

            \n
          1. Close coordination between the HD lead\ncoordinators from the historic QE and Heartlands sites with management of\nprogram capacity<\/li>\n\n\n\n
          2. Regular update calls with the units from the HD\nleadership team<\/li>\n\n\n\n
          3. Ongoing support for the satellite units to\npractice in a safe but more autonomous way<\/li>\n\n\n\n
          4. We now know that in a similar situation it is\npossible to successfully run the program using this command and control model<\/li>\n<\/ol>\n\n\n\n

            Maintaining social distancing at dialysis units<\/h3>\n\n\n\n

            To reduce the transmission of\nCovid-19 within dialysis units we encouraged the use of private rather than hospital\ntransport, we reduced the use of waiting areas and staggered shift start times\nto avoid mixing of patients from different shifts.<\/p>\n\n\n\n

            Management of staffing shortages: nurses who had previously worked in HD<\/h3>\n\n\n\n

            It was anticipated that Covid-19 was likely to bring\nsignificant staffing pressures, either as result of sickness or because of the\nneed to support dialysis in other areas such as ITU. A great effort was made to\nsupport those nurses who had previously worked in HD to return safely. Some of\nthese nurses (they were specialist nurses with an HD background) had been\nworking in an HD environment prior to Covid-19 so no training or additional\nsupport was required, some had not worked in HD for some time. The following\nmeasures were put in place to make the most effective use of this valuable\nresource;<\/p>\n\n\n\n

              \n
            1. An urgent assessment of all the nurses in the\norganisation who had HD skills was made by the matron at the outset<\/li>\n\n\n\n
            2. They were approached and an assessment of their\ntraining needs was made<\/li>\n\n\n\n
            3. A structured process of support and assessment\nwas put in place to ensure that that they were able to practice independently\nas quickly as possible<\/li>\n\n\n\n
            4. To maintain these skills they will all spend at\nleast half a day a month in HD going forward<\/li>\n<\/ol>\n\n\n\n

              Management of staffing shortages: medical students and sexual health nurses\nto work as HCAs and DSW<\/h3>\n\n\n\n

              We were able to utilise colleagues from the sexual health\nclinic and medical students to work at the dialysis units. They all had an\ninitial induction and were taken on to the unit to practice lining and priming,\nall redeployed staff were given a competency document and a mentor\/buddy to\nwork with. The Home HD CNS team also regularly visited the support workers on\nthe unit to support completion of the competency document. Informal feedback\nfrom both the dialysis teams and the staff themselves has been excellent.\nAlthough the teams were a little reluctant at first as it felt like extra\npressure to train staff when they were already under pressure, they soon felt\nthe benefit. We are planning a formal evaluation initially with the medical\nstudents. We will keep the training documents up to date to ensure that should\nwe need to roll out similar changes in future we can do so at pace.<\/p>\n\n\n\n

              The use of technology to replace face to face activity in the satellite\nprogram<\/h3>\n\n\n\n

              The initial limited availability of clinical staff and the\non-going need to reduce footfall at dialysis units to protect patients has\ndriven a use of technology to provide care for our patients. We now use video\nconferencing technology for QA meetings, this is very time efficient (some of\nour units are located a long way from base and the travelling times were\nsignificant) and will work well in the long term. We have also introduced video\nand phone reviews in place of face to face reviews which enable staff to work\nremotely. An on-going issue is the need to sign paper dialysis prescriptions,\nwe have overcome this by arranging for non patient transport to bring the\nprescriptions back to the hub in a secure document wallet where they are\nre-written by the HD coordinators and sent back on the same day. <\/p>\n\n\n\n

              The rate of production of SOPs\/training documents and patient communication<\/h3>\n\n\n\n

              During Covid-19 we needed to rapidly respond to a fast\nmoving situation, this involved producing documents rapidly and communicating\nclearly and regularly with our patients. The core HD team were involved in this\neffort which resulted in a master SOP for managing Covid-19 in a dialysis\nprogram. The beneficial aspect of this is that we needed a unified HD SOP after\nthe merger and this can now be based on the Covid-19 document. We wrote to our\npatients regularly and also used social media to communicate important\nmessages.<\/p>\n\n\n\n

              Key messages<\/h3>\n\n\n\n