Implementation of a pre-dialysis clinical pathway for patients with chronic kidney disease

Abstract

OBJECTIVE: The objective of this study was to design and implement an efficient pathway to ensure a smooth transition of patients with advanced chronic kidney disease to dialysis. SETTING: In our dialysis service, as elsewhere, we recognized that there was an unacceptably high rate of inadequately prepared patients commencing dialysis. Knowledge of clinical practice and research-based guidelines has not in itself changed clinical practice and patient management. MAIN MEASURE: : To address these problems, multidisciplinary process redesign teams reviewed pre-existing arrangements by assessing current practice. The review identified critical points where problems could occur: failure to notify patients to dialysis service, late referral for vascular surgery, and inadequate pre-dialysis education. As a result of this process, we have formulated a modified and coordinated pre-dialysis programme. RESULTS: In association with process redesign, the proportion of patients registered 'late' decreased from 29% in July-September 2000 (pre-implementation) to 6% in January-March 2004 (P < 0.01) with the corresponding median time from registration to commencement of dialysis increasing from <1 month to 14 months (P < 0.01). Patients not registered with the service decreased from 57 to 0% (P < 0.001). Eighty-three per cent of patients commenced dialysis with a permanent vascular access in January-March 2004, compared with 24% in July-September 2000 (P < 0.001). CONCLUSIONS: Through process redesign, more of our patients are known to us before commencement of dialysis, a greater proportion of which are provided with pre-dialysis education and permanent vascular access. Our results highlight that implementation remains the final and most difficult challenge of the guideline process.