Background: Best practice in dialysis is synthesised in clear international guidelines. However, a large gap remains between the international guidelines and the actual delivery of care. In this paper, we report outcomes for the first year of a multifaceted dialysis improvement programme in our network. Methods: One year collaborative involving 3 haemodialysis units and a peritoneal dialysis (PD) programme involving 299 dialysis patients. Each unit addressed a different indicator (unit A - catheter-related bloodstream infection [CRBSI], unit B - pre-dialysis blood pressure [BP], unit C - dialysis dose, unit D - anaemia) with a shared aim to match the top 10% in the UK. Tailored multifaceted approaches include a modified collaborative methodology with an aim, framework, driver diagram, learning sessions, facilitated meetings, plan-do-study-act cycles and continuous measurement. Analysis of outcomes, costings, erythropoietin stimulating agent and iron use, and safety culture attributes. Results: Unit A reduced CRBSI from 2.65 to 0.5 per 1,000 catheter days (p = 0.02). Unit B improved attainment of target BP from 37.5 to 67.2% (p = 0.003). Unit C improved attainment of target urea reduction ratio from 75.8 to 91.4% (p = 0.04). PD unit D improved attainment of target haemoglobin from 45.5 to 62.7% (p = 0.01), with no significant change in the indicators in a non-intervention unit. Safety culture attributes improved. Costs associated with admission for fluid overload and infection, erythropoietin, iron and thrombokinase use decreased 36% (£415,620-£264,143). Conclusions: Units that took part in this collaborative improved guideline adherence compared both to their own pre-intervention performance and a non-intervention unit. Such multifaceted interventions are a useful methodology to improve dialysis care.

Keywords:
Dialysis, Quality improvement, Outcomes, Quality, Clinical standards
1.
Nagler EV, Webster AC, Bolignano D, Haller MC, Nistor I, van der Veer SN, Fouque D, Van Biesen W: European renal best practice (ERBP) guideline development methodology: towards the best possible guidelines. Nephrol Dial Transplant 2014;29:731-738.
2.
Kasiske BL, Wheeler DC: Kidney disease: improving global outcomes - an update. Nephrol Dial Transplant 2014;29:763-769.
3.
Stevens PE, Tomson CR: Guidelines in the United Kingdom and how they are used. Clin J Am Soc Nephrol 2009;4(suppl 1):S23-S29.
4.
Mactier R, Hoenich N, Breen C: Renal association clinical practice guideline on haemodialysis. Nephron Clin Pract 2011;118(suppl 1):c241-c286.
5.
Boddana P, Caskey F, Casula A, Ansell D: UK renal registry 11th annual report (December 2008): chapter 14 UK renal registry and international comparisons. Nephron Clin Pract 2009;111(suppl 1):c269-c276.
6.
Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, The National Academies Press, 2001.
7.
van der Veer SN, Jager KJ, Nache AM, Richardson D, Hegarty J, Couchoud C, de Keizer NF, Tomson CR: Translating knowledge on best practice into improving quality of RRT care: a systematic review of implementation strategies. Kidney Int 2011;80:1021-1034.
8.
Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Grol RP: Evidence for the impact of quality improvement collaboratives: systematic review. BMJ 2008;336:1491-1494.
9.
Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA: Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The cochrane effective practice and organization of care review group. BMJ 1998;317:465-468.
10.
Davis DA, Taylor-Vaisey A: Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997;157:408-416.
11.
Williams AJ, Castledine C, Casula A, Warwick G: UK renal registry 12th annual report (December 2009): chapter 8: adequacy of haemodialysis in UK renal centres in 2008: national and centre-specific analyses. Nephron Clin Pract 2010;115(suppl 1):c145-c152.
12.
Richardson D, Ford D, Gilg J, Williams A: UK renal registry 12th annual report (December 2009): chapter 9: anaemia variables in UK adult dialysis patients in 2008: national and centre-specific analyses. Nephron Clin Pract 2010;115(suppl 1):c153-c186.
13.
Harper J, Nicholas J, Webbc L, Casula A, Williams AJ: UK renal registry 12th annual report (December 2009): chapter 11: blood pressure profile of prevalent patients receiving dialysis in the UK in 2008: national and centre-specific analyses. Nephron Clin Pract 2010;115(suppl 1):c239-c260.
14.
Dawnay A, Farrington K, Castledine C, van Schalkwyk D, Warwick G: UK renal registry 12th annual report (December 2009): chapter 10: biochemistry profile of patients receiving dialysis in the UK in 2008: national and centre-specific analyses. Nephron Clin Pract 2010;115(suppl 1):c187-c237.
15.
Hacking JM, Muller S, Buchan IE: Trends in mortality from 1965 to 2008 across the English north-south divide: comparative observational study. BMJ 2011;342:d508.
16.
Bate P, Robert G, Fulop N, Ovretveit J, Dixon-Woods M: Perspectives on Context: Health Foundation, 2014.
17.
Sorra JS, Dyer N: Hospital Survey on Patient Safety Culture. Rockville, Agency for Healthcare Research and Quality, 2004.
18.
The breakthrough series: IHI's Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series White Paper. Boston, Institute for Healthcare Improvement, 2003.
19.
Port FK, Pisoni RL, Bragg-Gresham JL, Satayathum SS, Young EW, Wolfe RA, Held PJ: DOPPS estimates of patient life years attributable to modifiable hemodialysis practices in the United States. Blood Purif 2004;22:175-180.
20.
Mactier R: UK Clinical Practice Guidelines: Module 2, Haemodialysis. UK, Renal Association, 2007.
21.
Pastan S, Soucie JM, McClellan WM: Vascular access and increased risk of death among hemodialysis patients. Kidney Int 2002;62:620-626.
22.
Patel PR, Yi SH, Booth S, Bren V, Downham G, Hess S, Kelley K, Lincoln M, Morrissette K, Lindberg C, Jernigan JA, Kallen AJ: Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis 2013;62:322-330.
23.
George A, Tokars JI, Clutterbuck EJ, Bamford KB, Pusey C, Holmes AH: Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: prospective study. BMJ 2006;332:1435.
24.
Zager PG, Nikolic J, Brown RH, Campbell MA, Hunt WC, Peterson D, Van Stone J, Levey A, Meyer KB, Klag MJ, Johnson HK, Clark E, Sadler JH, Teredesai P: “U” curve association of blood pressure and mortality in hemodialysis patients. Medical directors of dialysis clinic, Inc. Kidney Int 1998;54:561-569.
25.
Agarwal R, Peixoto AJ, Santos SF, Zoccali C: Pre- and postdialysis blood pressures are imprecise estimates of interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol 2006;1:389-398.
26.
Kidney Disease Outcomes Quality Initiative (K/DOQI): K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis 2004;43(5 suppl 1):S1-S290.
27.
Berwick DM: Developing and testing changes in delivery of care. Ann Intern Med 1998;128:651-656.
28.
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C, Wilcox MH: Epic2: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007;65(suppl 1):S1-S64.
29.
Farrington K, Hodsman A, Casula A, Ansell D, Feehally J: UK renal registry 11th annual report (December 2008): chapter 4 ESRD prevalent rates in 2007 in the UK: national and centre-specific analyses. Nephron Clin Pract 2009;111(suppl 1):c43-c68.
30.
Ovretveit J, Gustafson D: Evaluation of quality improvement programmes. Qual Saf Health Care 2002;11:270-275.
31.
Davenport A, Cox C, Thuraisingham R: Achieving blood pressure targets during dialysis improves control but increases intradialytic hypotension. Kidney Int 2008;73:759-764.
32.
Agarwal R, Alborzi P, Satyan S, Light RP: Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Hypertension 2009;53:500-507.
33.
Depner T, Daugirdas J, Greene T, Allon M, Beck G, Chumlea C, Delmez J, Gotch F, Kusek J, Levin N, Macon E, Milford E, Owen W, Star R, Toto R, Eknoyan G: Dialysis dose and the effect of gender and body size on outcome in the HEMO study. Kidney Int 2004;65:1386-1394.
34.
Port FK, Wolfe RA, Hulbert-Shearon TE, McCullough KP, Ashby VB, Held PJ: High dialysis dose is associated with lower mortality among women but not among men. Am J Kidney Dis 2004;43:1014-1023.
35.
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-2732.
36.
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-499.
37.
Russ SJ, Sevdalis N, Moorthy K, Mayer EK, Rout S, Caris J, Mansell J, Davies R, Vincent C, Darzi A: A qualitative evaluation of the barriers and facilitators toward implementation of the who surgical safety checklist across hospitals in England: lessons from the “surgical checklist implementation project”. Ann Surg 2015;261:81-91.
38.
Treadwell JR, Lucas S, Tsou AY: Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014;23:299-318.
39.
Uhlig K, Levey AS: Improving practice: reporting quality improvement activities. Am J Kidney Dis 2007;50:5-7.
40.
Johansen KL: Value of quality improvement reporting. Clin J Am Soc Nephrol 2007;2:1104-1105.
41.
Fink JC, Gardner JF, Armistead NC, Turner MS, Light PD: Within-center correlation in dialysis adequacy. J Clin Epidemiol 2000;53:79-85.
42.
Fink JC, Zhan M, Blahut SA, Soucie M, McClellan WM: Measuring the efficacy of a quality improvement program in dialysis adequacy with changes in center effects. J Am Soc Nephrol 2002;13:2338-2344.
43.
Parra E, Ramos R, Betriu A, Paniagua J, Belart M, Martinez T: Effect of a quality improvement strategy on several haemodialysis outcomes. Nephrol Dial Transplant 2008;23:2943-2947.
44.
Peters VJ, Clemons G, Augustine B: “Fistula first” as a CMS breakthrough initiative: improving vascular access through collaboration. Nephrol Nurs J 2005;32:686-687.
45.
Lacson E Jr, Lazarus JM, Himmelfarb J, Ikizler TA, Hakim RM: Balancing fistula first with catheters last. Am J Kidney Dis 2007;50:379-395.
46.
Plantinga LC, Fink NE, Jaar BG, Sadler JH, Levin NW, Coresh J, Klag MJ, Powe NR: Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: a prospective cohort study. BMC Health Serv Res 2007;7:5.
47.
Tentori F, Hunt WC, Rohrscheib M, Zhu M, Stidley CA, Servilla K, Miskulin D, Meyer KB, Bedrick EJ, Johnson HK, Zager PG: Which targets in clinical practice guidelines are associated with improved survival in a large dialysis organization? J Am Soc Nephrol 2007;18:2377-2384.
48.
Rocco MV, Frankenfield DL, Hopson SD, McClellan WM: Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis. Ann Intern Med 2006;145:512-519.
49.
Lacson E Jr, Wang W, Lazarus JM, Hakim RM: Hemodialysis facility-based quality-of-care indicators and facility-specific patient outcomes. Am J Kidney Dis 2009;54:490-497.
50.
Buttigieg SC, West MA, Dawson JF: Well-structured teams and the buffering of hospital employees from stress. Health Serv Manage Res 2011;24:203-212.
51.
West MA, Dawson JF: Employee Engagement and NHS Performance. The King's Fund, 2012.
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