ipcp 2006 ipcp 2006--2007: 2007: timely initiation of renal ......structured proactive patient...

IPCP 2006IPCP 2006--2007: 2007: Timely initiation of Renal Timely initiation of Renal Replacement Therapy in Replacement Therapy in

patients approaching end stage patients approaching end stage renal failure. renal failure.

Kwan THKwan TH, Au TC, Yung CY, , Au TC, Yung CY, SiuSiu G, Tong M, Leung F, Lee A, G, Tong M, Leung F, Lee A, Hau,AHau,A, Cheng HW, , Cheng HW, Leung D, Lee M, Lo H, Leung D, Lee M, Lo H, SzeSze WK, Lo SH, WK, Lo SH, ChuChu P, P, ChongChong A, A, LiangLiang J, To D, J, To D, KwongKwong WS, Ng S, WS, Ng S,

ShiaoShiao H, Ho KL, Wong L, Wu KK, Tang PF, Ho KK, Kwok A, Au B, Chow LH, Ho KL, Wong L, Wu KK, Tang PF, Ho KK, Kwok A, Au B, Chow LDivision of Renal Medicine Dept of M&G, Dept of FM, Dept of ClinDivision of Renal Medicine Dept of M&G, Dept of FM, Dept of Clinical Oncology,ical Oncology,

Dietetics, Pharmacy, CNS, MSW, NSD, ACCDietetics, Pharmacy, CNS, MSW, NSD, ACCTuenTuen MunMun HospitalHospitalNTW CLUSTERNTW CLUSTER

BackgroundBackground

•• Chronic Kidney Disease (CKD) is relatively Chronic Kidney Disease (CKD) is relatively asymptomatic till very late stage.asymptomatic till very late stage.

•• Most patients are reluctant to accept early Most patients are reluctant to accept early intervention until intervention until uremicuremic symptoms symptoms supervene. supervene.

•• Most are already dialysis dependent when Most are already dialysis dependent when TenckhoffTenckhoff’’ss catheter is implanted. catheter is implanted.


•• After After TenckhoffTenckhoff’’ss catheter (TC) implantation, catheter (TC) implantation, hospital intermittent peritoneal dialysis (IPD) hospital intermittent peritoneal dialysis (IPD) is required before maturation of access.is required before maturation of access.

•• Resource implication: Resource implication: –– Additional length of stay (LOS)Additional length of stay (LOS)–– Expenditure on PD fluid for IPDExpenditure on PD fluid for IPD


•• A new care plan for: A new care plan for: –– Strengthen patient / staff education for Strengthen patient / staff education for

CKD.CKD.–– Realign the logistics so that TC are inserted Realign the logistics so that TC are inserted

timely and electively when patients are less timely and electively when patients are less uremicuremic..

–– Ensure smooth transition to CAPD on Ensure smooth transition to CAPD on ambulatory basis without IPDambulatory basis without IPD

Presentation outlinePresentation outline–– The synthesis of the new IPCP.The synthesis of the new IPCP.–– The comparison between old and new care plan in The comparison between old and new care plan in

terms of various performance indicators: terms of various performance indicators: •• ALOS ALOS •• Expenditure on PD fluid before commencement Expenditure on PD fluid before commencement

of CAPD. of CAPD. •• ESI and peritonitis rate. ESI and peritonitis rate. •• Analysis on potential / actual saving achieved. Analysis on potential / actual saving achieved.

EducationGOPC +

Dept M&GStaff

HomeCAPDFlow Chart delineating the IPCP

for timely initiation of RRT in ESRF patients.

eGFReGFR estimation software incorporated in CMS.estimation software incorporated in CMS.

Copyright 2006 Dr Ashley Cheng

EducationGOPC +

Dept M&GStaff

Early Referral

ToRenalTeam



EducationGOPC +

Dept M&GStaff

ProactivePatient

Education

Early Referral

ToRenalTeam



Display of renal replacement therapy related pamphlets and objects during educational talk.

Educational pamphlets, booklets and CD

I

II III

IV

V

腎衰第一期腎衰第一期：腎過濾率：腎過濾率大過九成

腎衰第二期腎衰第二期：腎過濾率：腎過濾率六至九成

腎衰第三期：腎衰第三期：腎過濾率腎過濾率三至六成

腎衰第四期：腎衰第四期：腎過濾率腎過濾率成半至三成

腎衰第五期：腎衰第五期：腎過濾率於腎過濾率於少於一成半

慢性腎衰竭進展圖慢性腎衰竭進展圖

全世界腎科專家公認的全世界腎科專家公認的腎衰竭治療時序腎衰竭治療時序

•• 踏入腎衰第四期，腎過濾率下降至一踏入腎衰第四期，腎過濾率下降至一成半至三成時，應開始預備腎取代治成半至三成時，應開始預備腎取代治療，聽腎科講座，和腎科護理人員商療，聽腎科講座，和腎科護理人員商討治療計劃討治療計劃

古語有云：古語有云：

未雨綢繆未雨綢繆勝於勝於

臨渴掘井臨渴掘井

全世界腎科專家公認的全世界腎科專家公認的腎衰竭治療時序腎衰竭治療時序

•• 及早開始腎取代治療的病人，預後比中尿及早開始腎取代治療的病人，預後比中尿毒後才緊急安排透析的病人為佳。毒後才緊急安排透析的病人為佳。

•• 前者的體質得以保持在健康狀態，病者不前者的體質得以保持在健康狀態，病者不會經歷中尿毒各種難受的病徵。會經歷中尿毒各種難受的病徵。

•• 後者因中尿毒，體質下降，元氣大傷，瀕後者因中尿毒，體質下降，元氣大傷，瀕臨死亡時才開始透析，容易產生併發症，臨死亡時才開始透析，容易產生併發症，甚至危害生命。甚至危害生命。

Encouraging attendance of patient Encouraging attendance of patient education seminar in 2006education seminar in 2006

DateDate BookedBooked PatientPatientattendedattended

RelativeRelativeattendedattended

TotalTotal

FebFeb 2828 1919 1717 3636JunJun 3232 2626 2020 4646JulJul 2525 2020 1212 3232SepSep 2626 2222 2020 4242OctOct 3535 2828 1414 4242Nov Nov 2828 2424 2222 4646

Structured Proactive Patient Counseling Structured Proactive Patient Counseling and Education program for RRT and Education program for RRT

improves outcome in patient with ESRDimproves outcome in patient with ESRD

From Nov 2005 From Nov 2005 –– June 2006June 2006•• Counseled group: 25.8% (8/31) started CAPD Counseled group: 25.8% (8/31) started CAPD

while requiring bridging dialysis support. while requiring bridging dialysis support. •• NonNon--counseled group: 54.6% (34/57) patients counseled group: 54.6% (34/57) patients

started CAPD while requiring bridging dialysis started CAPD while requiring bridging dialysis support. P=0.001support. P=0.001

•• Tong MKH et al. HA Convention 2007 Poster Presentation.Tong MKH et al. HA Convention 2007 Poster Presentation.

EducationGOPC +

Dept M&GStaff

ProactivePatient

Education

Early Referral

ToRenalTeam

TimelyTreatment

Plan

NLC

RA

Triage



MSWDietetic CNS Pharmacy

Creation of NurseCreation of Nurse--Led ClinicLed Clinic

•• To coordinate patient education and multiTo coordinate patient education and multi--disciplinary intervention in CKD patients disciplinary intervention in CKD patients identified with estimated GFR from identified with estimated GFR from 15ml/min to 30ml/min who have attended 15ml/min to 30ml/min who have attended the CKD education seminar. the CKD education seminar.

Adjusted referral time frame for Adjusted referral time frame for Renal AssessmentRenal Assessment

•• Earlier elective referralEarlier elective referral of CKD patients for of CKD patients for renal assessment for those with renal assessment for those with eGFReGFR>10ml/min and 10ml/min and

Triage system of our IPCPTriage system of our IPCP

NLC/ Renal Assessment

Pre-emptiveRenal

Transplant

Private HD

ElectiveTC

Insertion

Renal Hospice

Hospital HD

EducationGOPC +

Dept M&GStaff

ProactivePatient

Education

Early Referral

ToRenalTeam

TimelyTreatment

Plan

NLC

RA

Triage

PreemptiveRT

HA/PrivateHD

Opt forCAPD

Renal Hospice

ElectiveTC

Insertion

WeeklyFlushing

CAPDtraining




Renal Hospice ServiceRenal Hospice Service

•• Collaboration between Department of M&G Collaboration between Department of M&G renal team and Clinical Oncology Department renal team and Clinical Oncology Department NTWC since end of 2004.NTWC since end of 2004.

•• Cater for CKD cases seen in renal assessment, Cater for CKD cases seen in renal assessment, NLC, or low clearance clinic, found not suitable NLC, or low clearance clinic, found not suitable or decided not to opt for RRT.or decided not to opt for RRT.

Scopes of renal hospice service.Scopes of renal hospice service.

•• Out patient clinicOut patient clinic counseling and assessment. counseling and assessment. •• In patient consultationIn patient consultation in medical wardin medical ward•• OutOut--reach nursing servicesreach nursing services::

–– Home care visitHome care visit–– Regular nurse ward visitRegular nurse ward visit–– Pre and post admission ward visitPre and post admission ward visit–– Phone visit and consultationPhone visit and consultation–– Interview and counseling Interview and counseling –– PostPost--bereavement counselingbereavement counseling

Response to renal hospice serviceResponse to renal hospice service

•• Client satisfaction survey July 2006: Client satisfaction survey July 2006: –– Out of 56 sample received (12 patients, 44 relatives)Out of 56 sample received (12 patients, 44 relatives)–– 93% clients satisfied93% clients satisfied with the service. with the service. –– Among 26 samples received home care services, Among 26 samples received home care services,

96% client satisfied96% client satisfied with home care visit. with home care visit. •• Number of TC insertion from 1Number of TC insertion from 1stst April to 30April to 30thth

September diminished from 68 in 2005 to 57 in September diminished from 68 in 2005 to 57 in 2006.2006.

EducationGOPC +

Dept M&GStaff

ProactivePatient

Education

Early Referral

ToRenalTeam

TimelyTreatment

Plan

NLC

RA

Triage

PreemptiveRT

HA/PrivateHD

Opt forCAPD

Renal Hospice

ElectiveTC

Insertion

WeeklyFlushing

CAPDtraining




Amendment of protocol and Amendment of protocol and workflow for elective TC insertionworkflow for elective TC insertion

•• Proposed time for elective TC insertionProposed time for elective TC insertioneGFReGFR from 8 to 10ml/min. from 8 to 10ml/min.

•• Adequate T.C. insertion sessions by surgical Adequate T.C. insertion sessions by surgical colleagues and renal physicians. colleagues and renal physicians.

•• Abolished post TC insertion IPD. Abolished post TC insertion IPD. •• Replaced by brief flushing protocol in day center Replaced by brief flushing protocol in day center

(Q1W x 4/52) (Q1W x 4/52)

EducationGOPC +

Dept M&GStaff

ProactivePatient

Education

Early Referral

ToRenalTeam

TimelyTreatment

Plan

NLC

RA

Triage

PreemptiveRT

HA/PrivateHD

Opt forCAPD

Renal Hospice

UnplannedOr AcutePresentation

ElectiveTC

Insertion

UrgentTC

Insertion

IntermittentHD

Support

WeeklyFlushing

CAPDtraining




Report of flushing programReport of flushing program11--44--06 to 3006 to 30--99--0606

•• 34 cases enrolled.34 cases enrolled.•• 60% of all cases of primary insertion of TC prior 60% of all cases of primary insertion of TC prior

CAPD training.CAPD training.•• On completion of CAPD training, if On completion of CAPD training, if eGFReGFR still still

> 6ml/min while patient remained > 6ml/min while patient remained asymptomatic CAPD may be suspended p.r.n. asymptomatic CAPD may be suspended p.r.n. and restart when needed. and restart when needed.

Comparison of patient characteristics between 3 groupsComparison of patient characteristics between 3 groupsNew care planNew care planOld care plan: Old care plan:

IPD (N=68)IPD (N=68)HD (N=23)HD (N=23) Flushing (N=34)Flushing (N=34)

AgeAge 58.658.6±±13.313.3 57.3 57.3 ±±11.411.4 62.8 62.8 ±±10.3 NS10.3 NS

Sex M: FSex M: F 41:2741:27 9:149:14 20:14 NS20:14 NS

DMDM 41.2%41.2% 34.8%34.8% 64.7% NS64.7% NS

BWBW 62.7 62.7 ±±14.714.7 58.0 58.0 ±±17.617.6 62.5 62.5 ±± 13.6 NS13.6 NS

HBHB 8.55 8.55 ±±1.141.14 8.2 8.2 ±±1.61.6 **9.4 9.4 ±±1.4 P=0.0021.4 P=0.002

UreaUrea 34.2 34.2 ±±9.79.7 41.5 41.5 ±±15.115.1 **30.4 30.4 ±±6.0 P=0.0196.0 P=0.019

CreatinineCreatinine 883.9 883.9 ±±349.2349.2 1154 1154 ±±526.0526.0 **685.3 685.3 ±±144.6 P

Actual savings on PD fluid Actual savings on PD fluid utilization for IPD in NTWCutilization for IPD in NTWC

•• Consumption of PD fluid for IPD in medical and renal Consumption of PD fluid for IPD in medical and renal ward from 1ward from 1stst April to 30April to 30thth September 2005: $589255September 2005: $589255

•• Consumption of PD fluid for IPD in medical and renal Consumption of PD fluid for IPD in medical and renal ward from 1ward from 1stst April to 30April to 30thth September 2006: $106728September 2006: $106728

•• Saving achieved in half year : $482527Saving achieved in half year : $482527•• Projected saving per financial year : ~$1MProjected saving per financial year : ~$1M

Change in LOS from TC insertion to Change in LOS from TC insertion to start of CAPDstart of CAPD

Old modelOld model New Care PlanNew Care PlanInIn--patient IPDpatient IPD11--4 to 304 to 30--99--0505N = 68N = 68

HD break inHD break in11--4 to 304 to 30--99--0606N= 23N= 23

FlushingFlushing11--4 to 304 to 30--99--0606N=34N=34

Length of Length of Stay (days)Stay (days)

15.6+15.6+-- 9.79.7 11.7+11.7+--6.06.0Actually 2 days Actually 2 days plus 9.7+plus 9.7+--6.0 HD 6.0 HD sessionssessionsP=0.074P=0.074

5.9+5.9+--0.80.8Actually 2 days Actually 2 days plus 3.9+plus 3.9+--0.8 half0.8 half--day stay in day day stay in day centre for flushing.centre for flushing.P

LOS analysis for old care plan LOS analysis for old care plan vsvs new care plannew care plan

•• IPD group total LOS = 15.6 x 68IPD group total LOS = 15.6 x 68= 1060.8= 1060.8

•• HD group total LOS = 11.7 x 23HD group total LOS = 11.7 x 23= 269.1= 269.1

•• Flushing group total LOS = 5.9 x 34Flushing group total LOS = 5.9 x 34= 200.6= 200.6

Reduction in total LOS in 6 monthsReduction in total LOS in 6 months= 1060.8 = 1060.8 -- 269.1 269.1 -- 200.6 = 591.1200.6 = 591.1

Projected annual reduction in LOSProjected annual reduction in LOS = 1182.2 = 1182.2 days days ~ 1200 days~ 1200 days..

Annual reduction of Annual reduction of avoidable hospitalization avoidable hospitalization up to ~1200 patientup to ~1200 patient--days.days.

Costing analysis for old care plan Costing analysis for old care plan vsvsnew care plannew care plan

•• Annual Annual nominalnominal cost reduction due to cost reduction due to reduction in hospital stay isreduction in hospital stay is roughly roughly $2652 x 1200 ~ $2652 x 1200 ~ 3.1 M3.1 M

•• Annual Annual actualactual cost reduction in PD fluid for cost reduction in PD fluid for IPD ~ 1 M IPD ~ 1 M

Total annual saving ~ 4MTotal annual saving ~ 4M

ESI rate and peritonitis rateESI rate and peritonitis rate

Old modelOld model11--44--05 to05 to3030--99--0505

HDHD11--44--06 to06 to3030--99--0606

FlushingFlushing11--44--06 to06 to3030--99--0606

New C.P.New C.P.11--44--06 to06 to3030--99--0606

Exit Site Exit Site InfectionInfection

8/688/68 2/232/23 3/343/34 5/575/57P=0.77P=0.77

PeritonitisPeritonitis 2/682/68 2/232/23 0/340/34 2/572/57P=1.0P=1.0

All All infectionsinfections

9/689/68 5/575/57P=0.57P=0.57

ESI rate and peritonitis rateESI rate and peritonitis rateOld modelOld model

11--44--05 to05 to3030--99--0505

HD break inHD break in

11--44--06 to06 to3030--99--0606

FlushingFlushing

11--44--06 to06 to3030--99--0606

New C.P.New C.P.

11--44--06 to06 to3030--99--0606

Time TC insertion Time TC insertion to CAPD (days)to CAPD (days)

37.237.2±±12.412.4

39.9 39.9 ±±21.121.1

38.5 38.5 ±±12.012.0

Exit Site InfectionExit Site Infection

(1 in patient(1 in patient--month)month)1 in 10.51 in 10.5 1 in 15.31 in 15.3 1 in 14.51 in 14.5 1 in 14.81 in 14.8

PeritonitisPeritonitis

(1 in patient(1 in patient--month)month)1 in 42.21 in 42.2 1 in 15.31 in 15.3 1 in 1 in ∞∞ 1 in 37.11 in 37.1

Impression: trend towards better ESI infection rate and peritonitis rateEspecially in flushing group though not yet reaching stat. significance

Rooms for improvementRooms for improvement

•• Reinforce staff education on early referral. Reinforce staff education on early referral. •• Reinforce patient education. Target on Reinforce patient education. Target on

defaulters to renal education programsdefaulters to renal education programs•• Reinforce nursing support to further lower ESI Reinforce nursing support to further lower ESI

and peritonitis rate.and peritonitis rate.

Conclusion:Conclusion:

•• New care plan enables timely initiation of RRT New care plan enables timely initiation of RRT in patients approaching ESRF resulting in in patients approaching ESRF resulting in satisfactory parameters in terms in ALOS, satisfactory parameters in terms in ALOS, complication rate. complication rate.

•• Patients are enrolled into RRT program at better Patients are enrolled into RRT program at better shape shape

•• Very significant actual/ nominal cost saving up Very significant actual/ nominal cost saving up to $4M/yr with reduction in LOS up to ~1200 to $4M/yr with reduction in LOS up to ~1200 daysdays

AcknowledgementAcknowledgement

•• This care plan is a collaborative effort resulting This care plan is a collaborative effort resulting from multidisciplinary input from the following from multidisciplinary input from the following parties:parties:–– Dept of M&G (medical, nursing and administrative staffs)Dept of M&G (medical, nursing and administrative staffs)–– Dept of Clinical oncologyDept of Clinical oncology–– Dept of Family MedicineDept of Family Medicine–– PharmacyPharmacy–– DieteticsDietetics–– MSWMSW–– CNSCNS–– NSDNSD–– ACCACC

•• Appreciates all the input from the above parties!Appreciates all the input from the above parties!


•• Cost for hospital stay x 1 day = $ 2652 Cost for hospital stay x 1 day = $ 2652 •• IPD group ALOS: 15.6 daysIPD group ALOS: 15.6 days

–– Mean expenditure: 15.6 x 2652= $41371.2 Mean expenditure: 15.6 x 2652= $41371.2 •• HD group ALOS: 2 HD group ALOS: 2 days + 9.7 HDdays + 9.7 HD

–– Mean expenditure: 2 x 2652 + 9.7x 1676 =$21561.2Mean expenditure: 2 x 2652 + 9.7x 1676 =$21561.2•• Flushing group ALOS: 2 days + 3.9 day stayFlushing group ALOS: 2 days + 3.9 day stay

–– Mean expenditure: 2 x 2652 + 3.9 x 2652 =$15646.8Mean expenditure: 2 x 2652 + 3.9 x 2652 =$15646.8


•• IPD group mean expenditure on LOS IPD group mean expenditure on LOS = $41371.2 (N = 68)= $41371.2 (N = 68)

•• HD group mean expenditure on LOS HD group mean expenditure on LOS = $21561.2 (N = 23)= $21561.2 (N = 23)

•• Flushing group mean expenditure on LOS Flushing group mean expenditure on LOS = $15646.8 (N =34)= $15646.8 (N =34)


•• IPD group total expenditure on LOS IPD group total expenditure on LOS = $2813241.6 ~ 2.8M= $2813241.6 ~ 2.8M

•• HD group total expenditure on LOS HD group total expenditure on LOS = $495907.6 ~ 0.5M= $495907.6 ~ 0.5M

•• Flushing group total expenditure on LOS Flushing group total expenditure on LOS = $531991.2= $531991.2


•• HD + flushing group total expenditure on LOS HD + flushing group total expenditure on LOS ~ 0.5M + 0.5M~ 0.5M + 0.5M~ 1M~ 1M

•• Cost saving on LOS for old care plan Cost saving on LOS for old care plan vsvs new care new care plan from 1st Apr to 30th Sep 06 plan from 1st Apr to 30th Sep 06 vsvs 0505~ $2.8M ~ $2.8M -- $1M$1M~ $1.7M~ $1.7M

•• Projected annual saving on LOS ~ 3.5MProjected annual saving on LOS ~ 3.5M

Potential cost saving due to Potential cost saving due to reduction in LOS.reduction in LOS.

•• Average LOS for each IPD 2Average LOS for each IPD 2--3 days. 3 days. •• 4 weeks of IPD: 24 weeks of IPD: 2--3 days x 5 ~ 103 days x 5 ~ 10--15 days15 days•• 4 weeks of flushing: 2 days + 4 half day visits in short 4 weeks of flushing: 2 days + 4 half day visits in short

stay ward. ~ 6 daysstay ward. ~ 6 days•• For HD group: the in patient IPD stays are replaced For HD group: the in patient IPD stays are replaced

with 2 sessions of HD /week as out patient.with 2 sessions of HD /week as out patient.=> => Marked reduction in LOS.Marked reduction in LOS.

Potential saving on cost of PD fluid Potential saving on cost of PD fluid for IPDfor IPD

•• Old care planOld care plan. . –– First 3 IPD after TC insertion: 40 x 1L PD fluid/ IPDFirst 3 IPD after TC insertion: 40 x 1L PD fluid/ IPD–– Subsequent IPD: 30 X 2L PD fluid/ IPDSubsequent IPD: 30 X 2L PD fluid/ IPD=> => Consumption of huge amount of PD fluid for IPDConsumption of huge amount of PD fluid for IPD

•• New care plan.New care plan.–– Immediate after TC insertion: 5 x 1L PDImmediate after TC insertion: 5 x 1L PD–– Subsequent weekly follow up: Subsequent weekly follow up:

•• 22--3 X 1L PD fluid/ flushing for first 2 follow up.3 X 1L PD fluid/ flushing for first 2 follow up.•• 22--3 X 2L PD fluid/ flushing for next 2 follow up.3 X 2L PD fluid/ flushing for next 2 follow up.•• Thereafter until CAPD training flush p.r.n. only.Thereafter until CAPD training flush p.r.n. only.

=> => Utilization of much less PD fluid during break in Utilization of much less PD fluid during break in period.period.


•• Average cost for HD consumables /HD sessionAverage cost for HD consumables /HD session–– HD concentrate HD concentrate –– DialyzersDialyzers–– Blood linesBlood lines–– Saline and miscellaneous consumablesSaline and miscellaneous consumables–– Access (double lumen catheters)Access (double lumen catheters)–– TOTAL: $ 1676 per HD treatment.TOTAL: $ 1676 per HD treatment.This is still cheaper than cost of one day of This is still cheaper than cost of one day of

hospital stay: $2652hospital stay: $2652


DateDate BookedBooked PatientPatient

attendedattended

RelativeRelative

attendedattended

TotalTotal

JanJan 2222 1414 1010 2424FebFeb 2828 1919 1717 3636MarMar 2121 1717 1212 2929AprApr 2727 1616 1414 3030May May 2121 1616 1010 2626JunJun 3232 2626 2020 4646


DateDate BookedBooked PatientPatientattendedattended

RelativeRelativeattendedattended

TotalTotal

JulJul 2525 2020 1212 3232AugAug 2323 1818 2020 2828SepSep 2626 2222 2020 4242OctOct 3535 2828 1414 4242Nov Nov 2828 2424 2222 4646DecDec 1818 1010 77 1717

IPCP 2006-2007: �Timely initiation of Renal Replacement Therapy in patients approaching end stage renal failure. �BackgroundBackgroundBackgroundPresentation outline全世界腎科專家公認的�腎衰竭治療時序古語有云：��未雨綢繆�勝於�臨渴掘井全世界腎科專家公認的�腎衰竭治療時序Encouraging attendance of patient education seminar in 2006Structured Proactive Patient Counseling and Education program for RRT improves outcome in patient with ESRDCreation of Nurse-Led ClinicAdjusted referral time frame for �Renal AssessmentTriage system of our IPCPRenal Hospice ServiceScopes of renal hospice service.Response to renal hospice serviceAmendment of protocol and workflow for elective TC insertionReport of flushing program�1-4-06 to 30-9-06Comparison of patient characteristics between 3 groupsActual savings on PD fluid utilization for IPD in NTWCChange in LOS from TC insertion to start of CAPD LOS analysis for old care plan �vs new care planAnnual reduction of avoidable hospitalization up to ~1200 patient-days.Costing analysis for old care plan vs new care planESI rate and peritonitis rateESI rate and peritonitis rateRooms for improvementConclusion:AcknowledgementCosting analysis for old care plan vs new care planCosting analysis for old care plan vs new care planCosting analysis for old care plan vs new care planCosting analysis for old care plan vs new care planPotential cost saving due to reduction in LOS.Potential saving on cost of PD fluid for IPDCosting analysis for old care plan vs new care planEncouraging attendance of patient education seminar in 2006Encouraging attendance of patient education seminar in 2006

ipcp 2006 ipcp 2006--2007: 2007: timely initiation of renal ......structured proactive patient...

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