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South London Renal Clinical Alliance Transplant workstream

South London Renal Clinical Alliance Transplant workstream. Improving and Standardising Transplant Pathways Nizam Mamode Phanish Mysore. U=SGH J=Guys V=Royal Free W=Royal London X=WLRTC. Standardising Transplant Pathways. RR 2017 cohort incident to RRT 01/01/12-31/12/14.

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South London Renal Clinical Alliance Transplant workstream

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  1. South London Renal Clinical Alliance Transplant workstream Improving and Standardising Transplant Pathways Nizam Mamode Phanish Mysore

  2. U=SGH J=Guys V=Royal Free W=Royal London X=WLRTC

  3. Standardising Transplant Pathways RR 2017 cohort incident to RRT 01/01/12-31/12/14

  4. What do we want to achieve?

  5. AIM of TX Workstream • Improve waiting times for donor and recipient • identification to activation • activation to surgery • identification to donor nephrectomy (Donor identification-work up-referral to nephrologist-to surgeon-to surgery) • Improve pre-emptive listing and transplant rates • Pathway for highly sensitised long waiters (?>5y) • Equity of access to transplants – referring centres • Improve the patient experience

  6. Improve waiting times for donor and recipient • identification to activation • activation to surgery • identification to donor nephrectomy (Donor identification-work up-referral to nephrologist-to surgeon-to surgery) Action Plan • All centres to agree on 18 week pathway (For donors and recipients) • Renal Registry to help with collecting baseline data on-20 recipients (activated on DD list), 20 Donors, 20 living donor recipients • ?Transplant first tool for prospective data collection • Improving/Optimising recording of each step of the pathway in local renal database

  7. Action Plan Group TIP Appointment CXR, Bloods and hx checklist START CLOCK Referral received by transplant nurses 2-4 WEEKS Appointment for education 1-1 Appointment CXR, Bloods and hx checklist HIGH RISK Echo, MPS or DSE Does the patient have: 3 or more vascular risk factors incl >65 yrs old, Diabetes Hx PVD, smoker Recurrent access thrombosis/femoral tunnelled line 4-10 WEEKS Request work up tests and follow up results LOW RISK ECG or ETT, Echo Activate on tx list Fully worked up. Ask nephrologist to review and refer to surgeon 10-14 weeks WEEKS Appointment with surgeon Other outcome YES Request ilio-femoral doppler (arterial and venous) and carotid doppler 14-18 weeks NO Activate on tx list

  8. Donor identifies himself/herself to LD sister 1-2 weeks Work up starts BTS guideline recommends 18 wk from donor identification to surgery or listing on UKLKSS 4-8 weeks Work up complete 2 weeks Donor clinic appt, surgical referral letter 4-6 weeks Further tests Assessed by surgeon- Tx date given or register for KSS (18 weeks) Sector meeting before giving date

  9. Delays in listing: 1. Delay in referral to Tx team (letters need to be replaced by e- referrals) 2. Delay in tx nurses acting on referral (workforce issues, work load)- Increase in work-force, more efficient working- Request tests when referral received rather than waiting for patient education to happen 3. Sharing Cardiac tests, dopplers, GFR tests between centres- Discussions are being held with cardiac and radiology ODNs 4. Delay in nephrologist doing surgical referral letter )For low risk patients, pencil in surgical slot while awaiting nephrologist letter if work up looks fine)

  10. Surgical slots (Being discussed in SLRCA board meetings- sharing slots between Guys and SGH surgeons) • Each patient to have a transplant journey sheet that highlights tests they need, tick as they go along • Tx champion in each dialysis unit and PD unit who will liaise with Tx nurses

  11. Improve pre-emptive listing and transplant rates

  12. Pathway for highly sensitised long waiters (?>5y) • We will produce a guideline document for the region (Long waiters and difficult to transplant recipients who are likely to wait long)

  13. Improve the patient experience • Patient survey (Questionnaire designed to assess patient satisfaction with regards to recipient and donor pathway) to be given/sent with the activation letter: renal registry to help produce this

  14. Data collection tool • Used to identify patterns and reasons why patients are not listed for transplantation pre-emptively. • The Renal Registry will identify trends over time - you will have access to this along with the other units in South London • There are 3 parts to the data collection • Enhanced Dashboard data- Expansion of NHS England Renal Indicator 3 - Access to Transplantation - looks at patient starting dialysis and whether they were listed at that point • Transplant listing data- All patients listed in a quarter, and when they were listed in relation to starting dialysis • Summary- this is some additional data

  15. https://transplantfirst.renalreg.org/

  16. Dialysis starters: not acute starts, known to unit

  17. Charts

  18. Data entry: Transplant listing data Can enter date or not in dialysis started after listing Some extra reasons are available

  19. Charts

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