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Phosphate Control - secrets of good units

Approach similar in different hospitals. Strong multidisciplinary approachInvolving patient / patient education central to processCommitment to quality / competition' between areasDieticians actively changing treatment / holding prescriber statusUse of full range of phosphate bindersUse of ultra low calcium dialysate.

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Phosphate Control - secrets of good units

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    1. Phosphate Control - secrets of ‘good’ units Hugh Cairns on behalf of Tyrone Hospital, Royal Berkshire Hospital and King’s

    4. Approach similar in different hospitals Strong multidisciplinary approach Involving patient / patient education central to process Commitment to quality / ‘competition’ between areas Dieticians actively changing treatment / holding prescriber status Use of full range of phosphate binders Use of ultra low calcium dialysate

    5. Multidisciplinary approach Dietetic, pharmacist, nurse, doctor input Monthly reviews look at many factors - difficult for an individual to concentrate on all Importance of several individuals reviewing results regularly Education for patient comes from many sources and more frequently

    6. Patient Education Phosphate control depends on adherence / compliance Difficult for patients to understand reasons to control phosphate Anxiety about bone disease not an incentive for patients Focus on cardiovascular risk may make easier Need to educate repeatedly and in different ways Feedback of patient results - monthly sheet

    7. King’s HD Patient Information Sheet

    8. Quality control Monthly review of laboratory results Minimum dialysis nurse and doctor. Usually nurse, pharmacist, dietician and doctor Highlighting results outside of desired range Dieticians confirming compliance / adherence with medication / diet Specific clinic for patients with poor results - Bone Club (Reading) Patients seen 2 weekly by consultant/nurse/dietician Dramatically improved PO4 results

    9. Quality Control - competition Comparing results between HD areas Regular audit comparing with RA guidelines and between areas Regional audits / national audit (Fresenius) Annual audit - comparison with RR data

    10. King’s Monthly HD Audit Summary

    11. Dietetic Involvement Dieticians central to process Diet advice to patients Oversee choice of phosphate binders - check compliance / timing / palatability Empowered to change patients’ treatment Alter doses / change binders / change Vit D Write letters to GP / patient

    12. Ultra low calcium dialysate - Tyrone Hospital Use of 0.75 mmol Ca in selected patients Enables use of calcium containing phosphate binders Small number of patients cannot tolerate (paraesthesia, hypotension)

    13. Areas of Failure Significant minority of patients with persistently raised phosphate 10 -15% of patients - ethnic minorities, younger Mechanistic, ‘scientific’ approach to problem - ‘solve by changing phosphate binder’ Clinicians adopt fatalistic view

    14. Interventions to change behaviour Health Belief Model Individual perceptions Modifying factors Likelihood of action Locus of control - external v internal Beattie’s model of health promotion

    15. Beattie’s model of health promotion practice

    16. Refocus on patients with poor phosphate control Patient education Consider other approaches Counsellor Explore patients’ understanding Group patient sessions Education materials

    17. ‘Secrets’ of good phosphate control - Summary Phosphate can be controlled with good patient adherence to diet and binders Requires patient education from different sources and repeated frequently Audit and competition drives improvement Multidisciplinary approach - many minds / pairs of eyes Still fail in significant minority

    18. Steps to good phosphates 1. Recognising patients in whom phosphate raised Monthly blood tests ? Multi-disciplinary review 2. Patient Education Different individuals Information provided in different ways 3. Use range of dietary measures and phosphate binders 4. Feedback results to patients monthly 5. Monthly audit / competition / appraisal 6. Special clinic for persistent raised PO4

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